Provider Demographics
NPI:1861724700
Name:MARRA, PHILIP ANGELO (RPH)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:ANGELO
Last Name:MARRA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 GRAND ISLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2194
Mailing Address - Country:US
Mailing Address - Phone:716-775-1169
Mailing Address - Fax:716-775-1239
Practice Address - Street 1:2140 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-2194
Practice Address - Country:US
Practice Address - Phone:716-775-1169
Practice Address - Fax:716-775-1239
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030534-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist