Provider Demographics
NPI:1104488071
Name:SISAY, MARIATOU
Entity type:Individual
Prefix:
First Name:MARIATOU
Middle Name:
Last Name:SISAY
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 1:1011 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5134
Mailing Address - Country:US
Mailing Address - Phone:916-746-6827
Mailing Address - Fax:
Practice Address - Street 1:1011 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5134
Practice Address - Country:US
Practice Address - Phone:916-746-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH80578183500000X
WAPH60864255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH80578OtherPHARMACIST
WAPH60864255OtherPHARMACIST