Provider Demographics
NPI:1710219761
Name:ORTEGA, MARISA MIRANDA (RPH)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:MIRANDA
Last Name:ORTEGA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:ELSA
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:2219 MUSSER ST
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043-2361
Mailing Address - Country:US
Mailing Address - Phone:956-726-9822
Mailing Address - Fax:
Practice Address - Street 1:1301 GUADALUPE ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-5343
Practice Address - Country:US
Practice Address - Phone:956-724-1126
Practice Address - Fax:956-721-0642
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38470183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist