Basic Information
| Provider Information | |||||||||
| NPI: | 1770894875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COULON | ||||||||
| FirstName: | MARLISE | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 CAMP BOWIE BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761073836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177358185 | ||||||||
| FaxNumber: | 8177358130 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 N SAGINAW BLVD | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761791234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173067147 | ||||||||
| FaxNumber: | 8177639643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2010 | ||||||||
| LastUpdateDate: | 07/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 34600 | TX | Y | Pharmacy Service Providers | Pharmacist | 183500000X | 14353 | LA | N | Pharmacy Service Providers | Pharmacist |
No ID Information.