Provider Demographics
NPI:1689849804
Name:JOHN MANCHIN III
Entity Type:Organization
Organization Name:JOHN MANCHIN III
Other - Org Name:MANCHIN FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCHIN
Authorized Official - Suffix:III
Authorized Official - Credentials:BS
Authorized Official - Phone:304-367-9122
Mailing Address - Street 1:181 MIDDLETOWN CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2015
Mailing Address - Country:US
Mailing Address - Phone:304-367-9122
Mailing Address - Fax:304-367-9125
Practice Address - Street 1:181 MIDDLETOWN CIR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2015
Practice Address - Country:US
Practice Address - Phone:304-367-9122
Practice Address - Fax:304-367-9125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05523773336C0002X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111736OtherPK
WV3810011348Medicaid