Provider Demographics
NPI:1598015869
Name:CHOMAL, MANISH RAJKUMAR
Entity Type:Individual
Prefix:
First Name:MANISH
Middle Name:RAJKUMAR
Last Name:CHOMAL
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 1:2660 REIDVILLE RD STE 8
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-3512
Mailing Address - Country:US
Mailing Address - Phone:864-435-9400
Mailing Address - Fax:
Practice Address - Street 1:2660 REIDVILLE RD STE 8
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-3512
Practice Address - Country:US
Practice Address - Phone:864-435-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC718290Medicaid