Provider Demographics
NPI:1992941785
Name:WANIS, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:WANIS
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 1:2648 12TH SQ SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32968-5066
Mailing Address - Country:US
Mailing Address - Phone:772-538-4852
Mailing Address - Fax:
Practice Address - Street 1:4870 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34951-2244
Practice Address - Country:US
Practice Address - Phone:772-466-5163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-28
Last Update Date:2008-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist