Provider Demographics
NPI:1962747972
Name:BOBER, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BOBER
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 1:30333 SOUTHFIELD RD
Mailing Address - Street 2:T-2207
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1352
Mailing Address - Country:US
Mailing Address - Phone:248-430-0063
Mailing Address - Fax:
Practice Address - Street 1:30333 SOUTHFIELD RD
Practice Address - Street 2:T-2207
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1352
Practice Address - Country:US
Practice Address - Phone:248-430-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-02
Last Update Date:2012-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist