Provider Demographics
NPI:1265157879
Name:MARZOUK, MARIAM (SOLE)
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:MARZOUK
Suffix:
Gender:F
Credentials:SOLE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 JOHNNY CAKE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2235
Mailing Address - Country:US
Mailing Address - Phone:651-688-7041
Mailing Address - Fax:
Practice Address - Street 1:4241 JOHNNY CAKE RIDGE RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2235
Practice Address - Country:US
Practice Address - Phone:651-688-7041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124082183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN124082OtherPHARMACIST