Healthcare Provider Details

I. General information

NPI: 1649187758
Provider Name (Legal Business Name): DWAYNE KARLO MANZANILLO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9695 S MARYLAND PKWY
LAS VEGAS NV
89123-5950
US

IV. Provider business mailing address

6188 KINNOW PL
LAS VEGAS NV
89122-7779
US

V. Phone/Fax

Practice location:
  • Phone: 702-896-1283
  • Fax:
Mailing address:
  • Phone: 702-896-1283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25137
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: