Provider Demographics
NPI:1902177165
Name:LIDDICOAT, MARION ELISE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:ELISE
Last Name:LIDDICOAT
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 1:880 SUTTON WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5167
Mailing Address - Country:US
Mailing Address - Phone:530-271-1021
Mailing Address - Fax:530-271-1043
Practice Address - Street 1:880 SUTTON WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5167
Practice Address - Country:US
Practice Address - Phone:530-271-1021
Practice Address - Fax:530-271-1043
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist