Provider Demographics
NPI:1730293812
Name:MANAGUA INC
Entity Type:Organization
Organization Name:MANAGUA INC
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FRONT STORE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOHIT
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-627-0004
Mailing Address - Street 1:581 BLACKWOOD CLEMENTON RD
Mailing Address - Street 2:
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-5901
Mailing Address - Country:US
Mailing Address - Phone:856-627-0004
Mailing Address - Fax:
Practice Address - Street 1:581 BLACKWOOD CLEMENTON RD
Practice Address - Street 2:
Practice Address - City:LINDENWOLD
Practice Address - State:NJ
Practice Address - Zip Code:08021-5901
Practice Address - Country:US
Practice Address - Phone:856-627-0004
Practice Address - Fax:856-627-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS006883003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3144401OtherNCPDP PROVIDER IDENTIFICATION NUMBER
3144401OtherNCPDP PROVIDER IDENTIFICATION NUMBER