Provider Demographics
NPI:1699370676
Name:MAZZACONE, MARISA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MAZZACONE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:MAZZACONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:6099 INDIAN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6099 INDIAN RIVER RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-3813
Practice Address - Country:US
Practice Address - Phone:757-938-9580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022169821835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist