Provider Demographics
NPI:1548644164
Name:DOMIANO, MARIE
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:
Last Name:DOMIANO
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 1:201 SMALLACOMBE DR
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2616
Mailing Address - Country:US
Mailing Address - Phone:570-348-1300
Mailing Address - Fax:
Practice Address - Street 1:201 SMALLACOMBE DRIVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508
Practice Address - Country:US
Practice Address - Phone:510-348-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORP037003T183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist