Provider Demographics
NPI:1003406968
Name:MANEVAL, DOMINIC JAMES
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JAMES
Last Name:MANEVAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 LITTLE LEAGUE RD
Mailing Address - Street 2:
Mailing Address - City:JERSEY SHORE
Mailing Address - State:PA
Mailing Address - Zip Code:17740-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1916 LYCOMING CREEK RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1205
Practice Address - Country:US
Practice Address - Phone:570-326-5144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPI124803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist