Provider Demographics
NPI:1629670633
Name:LAMONT, MARIELA
Entity Type:Individual
Prefix:
First Name:MARIELA
Middle Name:
Last Name:LAMONT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 SW ATHENA DR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5507
Mailing Address - Country:US
Mailing Address - Phone:561-222-7706
Mailing Address - Fax:
Practice Address - Street 1:1750 SW GATLIN BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2777
Practice Address - Country:US
Practice Address - Phone:772-878-3022
Practice Address - Fax:772-878-3216
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55605183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist