Provider Demographics
NPI:1770894875
Name:COULON, MARLISE MARIA (RPH)
Entity type:Individual
Prefix:
First Name:MARLISE
Middle Name:MARIA
Last Name:COULON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-3836
Mailing Address - Country:US
Mailing Address - Phone:817-735-8185
Mailing Address - Fax:817-735-8130
Practice Address - Street 1:833 N SAGINAW BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179-1234
Practice Address - Country:US
Practice Address - Phone:817-306-7147
Practice Address - Fax:817-763-9643
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34600183500000X
LA14353183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist