Provider Demographics
NPI:1164759338
Name:MANICKATH, MARTIN D
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:D
Last Name:MANICKATH
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 1:2311 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-5353
Mailing Address - Country:US
Mailing Address - Phone:214-320-0892
Mailing Address - Fax:
Practice Address - Street 1:2311 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-5353
Practice Address - Country:US
Practice Address - Phone:214-320-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38933183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist