Provider Demographics
NPI:1912296583
Name:BOICE, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BOICE
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:PO BOX 1000
Mailing Address - Street 2:MS3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:207-396-2091
Practice Address - Street 1:27-41 GANSEVOORT ROAD
Practice Address - Street 2:
Practice Address - City:SOUTH GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12803
Practice Address - Country:US
Practice Address - Phone:518-798-2847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist