Provider Demographics
NPI:1902369499
Name:ELAIWA, MARIAM (RPH)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:ELAIWA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 SAFARI DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-4233
Mailing Address - Country:US
Mailing Address - Phone:408-886-1579
Mailing Address - Fax:
Practice Address - Street 1:1376 KOOSER RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-3813
Practice Address - Country:US
Practice Address - Phone:408-448-2503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA79853OtherCA STATE BOARD OF PHARMACY