Provider Demographics
NPI:1891319323
Name:MARATITA-LIZAMA, WINONA-REBEKAH BLANCO
Entity Type:Individual
Prefix:
First Name:WINONA-REBEKAH
Middle Name:BLANCO
Last Name:MARATITA-LIZAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2210
Mailing Address - Country:US
Mailing Address - Phone:503-842-5934
Mailing Address - Fax:
Practice Address - Street 1:8122 SE TIBBETTS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1768
Practice Address - Country:US
Practice Address - Phone:503-777-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist