Provider Demographics
NPI:1063709111
Name:EGLY, MARISSA (PHARMD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:EGLY
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 1:1015 N LOYALSOCK AVE
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-1065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 N LOYALSOCK AVE
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-1065
Practice Address - Country:US
Practice Address - Phone:570-368-5454
Practice Address - Fax:570-368-5456
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP445670183500000X
PARPI005017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist