Provider Demographics
NPI:1538287024
Name:YELISEVICH, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:YELISEVICH
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 1:3161 S OCEAN DRIVE
Mailing Address - Street 2:#1501
Mailing Address - City:HALLANDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 CORDOVA RD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2132
Practice Address - Country:US
Practice Address - Phone:954-467-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist