Provider Demographics
NPI:1932509734
Name:MANGULABNAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MANGULABNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 WOODHILL CT
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-9142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:702 BROWNING LN
Practice Address - Street 2:
Practice Address - City:BROOKLAWN
Practice Address - State:NJ
Practice Address - Zip Code:08030-2645
Practice Address - Country:US
Practice Address - Phone:856-456-7141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03645900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RJ05570OtherIMMUNIZATION APPROVAL