Provider Demographics
NPI:1720349145
Name:YUSUPOVA, MARIANNA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIANNA
Middle Name:
Last Name:YUSUPOVA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 BRIGHTON BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-7411
Mailing Address - Country:US
Mailing Address - Phone:718-648-0002
Mailing Address - Fax:718-648-0700
Practice Address - Street 1:274 BRIGHTON BEACH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-7411
Practice Address - Country:US
Practice Address - Phone:718-648-0002
Practice Address - Fax:718-648-0700
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051163OtherPHARMACIST