Provider Demographics
NPI:1295417673
Name:SIMMONS, MARISA ANNE (PHARM D)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ANNE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1357
Mailing Address - Country:US
Mailing Address - Phone:516-313-3928
Mailing Address - Fax:
Practice Address - Street 1:403 1ST AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-1357
Practice Address - Country:US
Practice Address - Phone:516-663-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070453-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist