Provider Demographics
NPI:1033712047
Name:MANZO, ERMANO MARIO (RPH)
Entity Type:Individual
Prefix:MR
First Name:ERMANO
Middle Name:MARIO
Last Name:MANZO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3544
Mailing Address - Country:US
Mailing Address - Phone:937-866-6651
Mailing Address - Fax:
Practice Address - Street 1:1205 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3544
Practice Address - Country:US
Practice Address - Phone:937-866-6651
Practice Address - Fax:937-866-6650
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03215480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03215480Medicaid
OHNAMedicaid