Provider Demographics
NPI:1629351697
Name:MANZULLO, JOSEPH P (RPH)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:P
Last Name:MANZULLO
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 1:112 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:ABSECON
Mailing Address - State:NJ
Mailing Address - Zip Code:08201-1632
Mailing Address - Country:US
Mailing Address - Phone:609-742-5563
Mailing Address - Fax:
Practice Address - Street 1:402 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2104
Practice Address - Country:US
Practice Address - Phone:609-742-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0004198183500000X
NJ28RI02634900183500000X
PARP445628183500000X
NY056259-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist