Provider Demographics
NPI:1821353236
Name:BOELHAUF, MARISSA MARCINEK (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:MARCINEK
Last Name:BOELHAUF
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 1:568 FOLKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4214
Mailing Address - Country:US
Mailing Address - Phone:859-619-5439
Mailing Address - Fax:
Practice Address - Street 1:3349 TATES CREEK RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-3467
Practice Address - Country:US
Practice Address - Phone:859-266-0413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist