Provider Demographics
NPI:1215641709
Name:AWAD, MARIUM
Entity type:Individual
Prefix:
First Name:MARIUM
Middle Name:
Last Name:AWAD
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 1:15 SAGECREST
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2425
Mailing Address - Country:US
Mailing Address - Phone:094-963-0667
Mailing Address - Fax:
Practice Address - Street 1:3865 JACKSON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3919
Practice Address - Country:US
Practice Address - Phone:951-688-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71508183500000X
CA75958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA75958OtherREGISTERED PHARMACIST LICENSE
TX71508OtherREGISTERED PHARMACIST LICENSE