Provider Demographics
NPI:1689956450
Name:DE FREITAS, MARIOVANI P (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARIOVANI
Middle Name:P
Last Name:DE FREITAS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67100 COUNTY ROAD 1
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-9516
Mailing Address - Country:US
Mailing Address - Phone:574-862-1628
Mailing Address - Fax:
Practice Address - Street 1:1755 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6425
Practice Address - Country:US
Practice Address - Phone:574-533-4932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020759A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist