MEDICARE: DR. WANA MANITPISITKUL PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	17787	MD

General Provider Information

NPI Number	:	1700176872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WANA MANITPISITKUL PHARM.D.

Provider Business Mailing Address
First Line	:	4960 WALKING STICK RD
Second Line	:	APT H
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-8058
Country	:	US
Telephone Number	:	410-328-9701
Fax Number	:

Provider Business Practice Location Address
First Line	:	4960 WALKING STICK RD
Second Line	:	APT H
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21043-8058
Country	:	US
Telephone Number	:	410-328-9701
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2011
Last Update Date	:	04/11/2011

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