Provider Demographics
NPI:1205040532
Name:MANOCHA, MADAN M (RPH)
Entity Type:Individual
Prefix:MR
First Name:MADAN
Middle Name:M
Last Name:MANOCHA
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 1:1005 DES PLAINES AVE
Mailing Address - Street 2:APARTMENT 202
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-2172
Mailing Address - Country:US
Mailing Address - Phone:708-771-4617
Mailing Address - Fax:
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist