Provider Demographics
NPI:1124792767
Name:RICHGRUBER, MARION DANIELA
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:DANIELA
Last Name:RICHGRUBER
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 1:170 BROOM SEDGE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-2164
Mailing Address - Country:US
Mailing Address - Phone:804-638-4389
Mailing Address - Fax:
Practice Address - Street 1:2655 REILLY ST BLDG 4-175
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-8757
Practice Address - Country:US
Practice Address - Phone:910-907-6112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25810183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist