Provider Demographics
NPI:1861747172
Name:SAN ROMAN, MARIE DOLORES (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARIE
Middle Name:DOLORES
Last Name:SAN ROMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N HIGHLAND SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3046
Mailing Address - Country:US
Mailing Address - Phone:951-769-4888
Mailing Address - Fax:
Practice Address - Street 1:600 N HIGHLAND SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3046
Practice Address - Country:US
Practice Address - Phone:951-769-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056900183500000X
CA68436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist