Provider Demographics
NPI:1790050227
Name:RISENMAY, MARYN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARYN
Middle Name:
Last Name:RISENMAY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 ROYCROFT PL
Mailing Address - Street 2:APT A
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1672 ROYCROFT PL
Practice Address - Street 2:APT A
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84124-2593
Practice Address - Country:US
Practice Address - Phone:801-319-2794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6432666-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist