Provider Demographics
NPI:1356732333
Name:SMITH, MARIE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:SMITH
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 1:25 S GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-1228
Mailing Address - Country:US
Mailing Address - Phone:540-374-4821
Mailing Address - Fax:540-374-4831
Practice Address - Street 1:25 S GATEWAY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-1228
Practice Address - Country:US
Practice Address - Phone:540-374-4821
Practice Address - Fax:540-374-4831
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230019799183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician