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General NPI Number Information
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NPI Number | 1437368651
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Entity Type | Organization
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Legal Business Name | MMJM INC
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 01/13/2017
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Provider Practice Location Address
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Address Line | 19 DUNDAFF ST 2ND FLOOR STE
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City | CARBONDALE
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State | PA
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Zip | 18407-1828
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Country | US
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Telephone | 570-282-1080
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Fax | 570-282-1815
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Provider Business Mailing Address
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Address Line | 19 DUNDAFF ST 2ND FLOOR STE
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City | CARBONDALE
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State | PA
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Zip | 18407-1828
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Country | US
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Telephone | 570-282-1080
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Fax | 570-282-1815
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Authorized Official
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Title or Position | PRES
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Name | MICHAEL MANCUSO
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Credential |
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Telephone | 570-282-6046
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | PP481717
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License Number State | PA
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