Provider Demographics
NPI:1063093995
Name:BLACK, MARIAH (PHARMD)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:
Last Name:BLACK
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 1:10506 W HAYDEN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-3533
Mailing Address - Country:US
Mailing Address - Phone:316-650-8333
Mailing Address - Fax:
Practice Address - Street 1:9211 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2900
Practice Address - Country:US
Practice Address - Phone:316-609-4501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-1008051835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care