Provider Demographics
NPI:1417247602
Name:SEBASTIAN, MANOJ (RPH)
Entity Type:Individual
Prefix:MR
First Name:MANOJ
Middle Name:
Last Name:SEBASTIAN
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 1:7063 SPARROW RDG
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3602
Mailing Address - Country:US
Mailing Address - Phone:269-270-3168
Mailing Address - Fax:
Practice Address - Street 1:560 JENNER DR
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1517
Practice Address - Country:US
Practice Address - Phone:269-673-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist