Provider Demographics
NPI:1316522881
Name:ISSAC, MARO
Entity type:Individual
Prefix:
First Name:MARO
Middle Name:
Last Name:ISSAC
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 1:12775 MILLENNIUM APT 309
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2970
Mailing Address - Country:US
Mailing Address - Phone:513-623-5513
Mailing Address - Fax:
Practice Address - Street 1:11795 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1211
Practice Address - Country:US
Practice Address - Phone:310-312-6506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83760183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty