Provider Demographics
NPI:1972134294
Name:AYSON, MARL
Entity type:Individual
Prefix:
First Name:MARL
Middle Name:
Last Name:AYSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27715 THALIA LN
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:349 E AVENUE K6
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4508
Practice Address - Country:US
Practice Address - Phone:661-723-4260
Practice Address - Fax:661-723-6975
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80993183500000X, 1835P1300X, 1835P2201X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care