Provider Demographics
NPI:1013239193
Name:PERRY, MARISA (BS)
Entity Type:Individual
Prefix:MISS
First Name:MARISA
Middle Name:
Last Name:PERRY
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HERITAGE PL
Mailing Address - Street 2:
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1634
Mailing Address - Country:US
Mailing Address - Phone:315-769-6547
Mailing Address - Fax:315-764-9500
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1901
Practice Address - Country:US
Practice Address - Phone:315-764-0559
Practice Address - Fax:315-764-9500
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050315-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist