Provider Demographics
NPI:1598048621
Name:MAN, CONNIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:MAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6170 THORNTON AVE STE E
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-3700
Mailing Address - Country:US
Mailing Address - Phone:510-961-1288
Mailing Address - Fax:
Practice Address - Street 1:6170 THORNTON AVE STE E
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-3700
Practice Address - Country:US
Practice Address - Phone:510-961-1288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68608183500000X
CA577083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacist