Provider Demographics
NPI:1548842214
Name:MARYMOOR PHARMACY, LLC
Entity type:Organization
Organization Name:MARYMOOR PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SIDDHARTH
Authorized Official - Middle Name:
Authorized Official - Last Name:VISWANATHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-353-5495
Mailing Address - Street 1:3121 DIABLO AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545
Mailing Address - Country:US
Mailing Address - Phone:650-353-5495
Mailing Address - Fax:650-435-5932
Practice Address - Street 1:2533 152ND AVE NE STE 14JK
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-5550
Practice Address - Country:US
Practice Address - Phone:425-968-8492
Practice Address - Fax:425-968-8534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE5198080OtherCERTIFICATE OF FORMATION