Healthcare Provider Details

I. General information

NPI: 1689849804
Provider Name (Legal Business Name): JOHN MANCHIN III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MIDDLETOWN CIR
FAIRMONT WV
26554-2015
US

IV. Provider business mailing address

181 MIDDLETOWN CIR
FAIRMONT WV
26554-2015
US

V. Phone/Fax

Practice location:
  • Phone: 304-367-9122
  • Fax: 304-367-9125
Mailing address:
  • Phone: 304-367-9122
  • Fax: 304-367-9125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberSP0552377
License Number StateWV

VIII. Authorized Official

Name: JOHN MANCHIN III
Title or Position: OWNER
Credential: B.S.
Phone: 304-367-9122