Provider Demographics
NPI:1629676663
Name:MANSOURATI, JOANA
Entity Type:Individual
Prefix:
First Name:JOANA
Middle Name:
Last Name:MANSOURATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BAYONNE CROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-5305
Mailing Address - Country:US
Mailing Address - Phone:201-620-6512
Mailing Address - Fax:201-620-6343
Practice Address - Street 1:500 BAYONNE CROSSING WAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-5305
Practice Address - Country:US
Practice Address - Phone:201-620-6512
Practice Address - Fax:201-620-6343
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03179500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist