Provider Demographics
NPI:1629815287
Name:WANIS, MARIAM AMIR FAHMY
Entity type:Individual
Prefix:MRS
First Name:MARIAM
Middle Name:AMIR FAHMY
Last Name:WANIS
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 1:1919 MINERAL SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-3722
Mailing Address - Country:US
Mailing Address - Phone:401-353-2501
Mailing Address - Fax:
Practice Address - Street 1:1919 MINERAL SPRING AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-3722
Practice Address - Country:US
Practice Address - Phone:401-353-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH06657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist