Provider Demographics
NPI:1770264764
Name:MASAK, MARIAN
Entity type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:
Last Name:MASAK
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 1:105 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2301
Mailing Address - Country:US
Mailing Address - Phone:908-355-0571
Mailing Address - Fax:908-355-0570
Practice Address - Street 1:105 BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2301
Practice Address - Country:US
Practice Address - Phone:908-355-0571
Practice Address - Fax:908-355-0570
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03884800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist