Provider Demographics
NPI:1427773712
Name:KUMAR, MARISSA S
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:S
Last Name:KUMAR
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 1:9904 STORM PETREL CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-6382
Mailing Address - Country:US
Mailing Address - Phone:916-524-3886
Mailing Address - Fax:
Practice Address - Street 1:5021 LAGUNA BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5262
Practice Address - Country:US
Practice Address - Phone:916-691-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist