Provider Demographics
NPI:1750873022
Name:IVERSON, MARISSA LEE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:LEE
Last Name:IVERSON
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 1:619 DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4325
Mailing Address - Country:US
Mailing Address - Phone:310-625-3686
Mailing Address - Fax:
Practice Address - Street 1:10945 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3717
Practice Address - Country:US
Practice Address - Phone:818-487-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-03
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125989333600000X
ND6469183500000X
CA77730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No333600000XSuppliersPharmacy