Provider Demographics
NPI:1679233480
Name:SMITH, MAHRYA MICHELLE
Entity Type:Individual
Prefix:
First Name:MAHRYA
Middle Name:MICHELLE
Last Name:SMITH
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 1:1751 FISHER DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-4064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 SAN RAMON VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4013
Practice Address - Country:US
Practice Address - Phone:925-743-0166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist