Healthcare Provider Details

I. General information

NPI: 1316702723
Provider Name (Legal Business Name): MARIUS PABLO MANANSALA CORDERO PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 HERNDON AVE
CLOVIS CA
93611-0504
US

IV. Provider business mailing address

5370 E HARVEY AVE
FRESNO CA
93727-2515
US

V. Phone/Fax

Practice location:
  • Phone: 559-322-0150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number89155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: