MEDICARE: SUDHEER MANTENA PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	3621	NH
2	183500000X	Pharmacist	PH232891	MA
3	183500000X	Pharmacist	54373	TX

General Provider Information

NPI Number	:	1073982062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUDHEER MANTENA PHD

Provider Business Mailing Address
First Line	:	42 ROYAL CREST DR
Second Line	:	4
City	:	NASHUA
State	:	NH
Zip	:	03060-6634
Country	:	US
Telephone Number	:	914-374-8463
Fax Number	:

Provider Business Practice Location Address
First Line	:	750 US ROUTE 202
Second Line	:
City	:	RINDGE
State	:	NH
Zip	:	03461-5615
Country	:	US
Telephone Number	:	603-899-6965
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2015
Last Update Date	:	09/19/2015

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Directions to “ SUDHEER MANTENA PHD” Practice Location

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