Provider Demographics
NPI:1134371339
Name:VAN DER MERWE, MARIANA
Entity type:Individual
Prefix:MRS
First Name:MARIANA
Middle Name:
Last Name:VAN DER MERWE
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 1:4648 CAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-6190
Mailing Address - Country:US
Mailing Address - Phone:707-444-2018
Mailing Address - Fax:
Practice Address - Street 1:725 SOUTH BOULEVARD
Practice Address - Street 2:RITE AID PHARMACY
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540
Practice Address - Country:US
Practice Address - Phone:707-725-9314
Practice Address - Fax:707-725-4056
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH58934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist