Provider Demographics
NPI:1588351704
Name:AVILA, MARISA
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:AVILA
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 1:47985 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6752
Mailing Address - Country:US
Mailing Address - Phone:760-347-3646
Mailing Address - Fax:760-342-0781
Practice Address - Street 1:47985 MONROE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6752
Practice Address - Country:US
Practice Address - Phone:760-347-3646
Practice Address - Fax:760-342-0781
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65243183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician