Provider Demographics
NPI:1942801436
Name:FARAH, MARIAM
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:FARAH
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 1:42706 STATE HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-9483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 N DOUGLASS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1515
Practice Address - Country:US
Practice Address - Phone:573-276-5735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20190356491835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist