Provider Demographics
NPI:1548592462
Name:MANNINO, BARTHOLOMEW LOUIS (RPH)
Entity Type:Individual
Prefix:
First Name:BARTHOLOMEW
Middle Name:LOUIS
Last Name:MANNINO
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 1:7407 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-5614
Mailing Address - Country:US
Mailing Address - Phone:718-331-5330
Mailing Address - Fax:718-331-3779
Practice Address - Street 1:7407 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-5614
Practice Address - Country:US
Practice Address - Phone:718-331-5330
Practice Address - Fax:718-331-3779
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-02
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33430-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01051298Medicaid