Provider Demographics
NPI:1033778964
Name:MANN, SURJIT
Entity Type:Individual
Prefix:
First Name:SURJIT
Middle Name:
Last Name:MANN
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 1:2100 STANDIFORD AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6523
Mailing Address - Country:US
Mailing Address - Phone:209-577-1350
Mailing Address - Fax:
Practice Address - Street 1:2100 STANDIFORD AVE STE B1
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6523
Practice Address - Country:US
Practice Address - Phone:209-577-1350
Practice Address - Fax:209-577-1409
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist