Provider Demographics
NPI:1093567968
Name:MANZANO, RICARDO EDGAR
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:EDGAR
Last Name:MANZANO
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 1:6995 W 4TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4948
Mailing Address - Country:US
Mailing Address - Phone:786-288-1139
Mailing Address - Fax:
Practice Address - Street 1:3251 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013
Practice Address - Country:US
Practice Address - Phone:305-888-3364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS66676183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist