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General NPI Number Information
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NPI Number | 1689849804
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Entity Type | Organization
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Legal Business Name | JOHN MANCHIN III
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Dates
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Enumeration Date | 04/29/2008
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Last Update Date | 04/25/2017
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Provider Practice Location Address
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Address Line | 181 MIDDLETOWN CIR
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City | FAIRMONT
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State | WV
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Zip | 26554-2015
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Country | US
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Telephone | 304-367-9122
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Fax | 304-367-9125
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Provider Business Mailing Address
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Address Line | 181 MIDDLETOWN CIR
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City | FAIRMONT
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State | WV
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Zip | 26554-2015
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Country | US
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Telephone | 304-367-9122
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Fax | 304-367-9125
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Authorized Official
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Title or Position | OWNER
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Name | JOHN MANCHIN III
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Credential | B.S.
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Telephone | 304-367-9122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | SP0552377
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License Number State | WV
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