Provider Demographics
NPI:1275537730
Name:MANCHESTER PHARMACY INC
Entity Type:Organization
Organization Name:MANCHESTER PHARMACY INC
Other - Org Name:MANCHESTER PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEESPEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:410-239-2300
Mailing Address - Street 1:PO BOX 886
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21102-0886
Mailing Address - Country:US
Mailing Address - Phone:410-239-2300
Mailing Address - Fax:410-239-4744
Practice Address - Street 1:3321 MAIN ST
Practice Address - Street 2:UNIT A1
Practice Address - City:MANCHESTER
Practice Address - State:MD
Practice Address - Zip Code:21102-1790
Practice Address - Country:US
Practice Address - Phone:410-239-2300
Practice Address - Fax:410-239-4744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-11
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP040293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD001789200Medicaid
MD000887700Medicaid
2037806OtherPK
MD000887700Medicaid