Provider Demographics
NPI:1427461813
Name:MERRICK, IDANA (RPH)
Entity type:Individual
Prefix:
First Name:IDANA
Middle Name:
Last Name:MERRICK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N SANDPIPER
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:TX
Mailing Address - Zip Code:78362-4684
Mailing Address - Country:US
Mailing Address - Phone:361-288-2580
Mailing Address - Fax:
Practice Address - Street 1:521 N SANDPIPER
Practice Address - Street 2:
Practice Address - City:INGLESIDE
Practice Address - State:TX
Practice Address - Zip Code:78362-4684
Practice Address - Country:US
Practice Address - Phone:361-288-2580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist