Provider Demographics
NPI:1851302038
Name:JM MANCUSO ENTERPRISE INC
Entity Type:Organization
Organization Name:JM MANCUSO ENTERPRISE INC
Other - Org Name:FIGLIOMENI DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:570-282-1410
Mailing Address - Street 1:19 DUNDAFF ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-1828
Mailing Address - Country:US
Mailing Address - Phone:570-282-1410
Mailing Address - Fax:570-282-4502
Practice Address - Street 1:19 DUNDAFF ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-1828
Practice Address - Country:US
Practice Address - Phone:570-282-1410
Practice Address - Fax:570-282-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410757L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101529550Medicaid
PA101529550Medicaid