Healthcare Provider Details

I. General information

NPI: 1932509734
Provider Name (Legal Business Name): MICHAEL MANGULABNAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 BROWNING LN
BROOKLAWN NJ
08030-2645
US

IV. Provider business mailing address

1013 WOODHILL CT
WILLIAMSTOWN NJ
08094-9142
US

V. Phone/Fax

Practice location:
  • Phone: 856-456-7141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03645900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: