Provider Demographics
NPI:1740606631
Name:MANNISI, ALFONSO (RPH)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:MANNISI
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 1:27 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-9630
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07522-1721
Practice Address - Country:US
Practice Address - Phone:973-790-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-15
Last Update Date:2014-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01645200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist