Provider Demographics
NPI:1134580038
Name:MANIYATTE, SUBY
Entity type:Individual
Prefix:
First Name:SUBY
Middle Name:
Last Name:MANIYATTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BIG ELK MALL
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-6035
Mailing Address - Country:US
Mailing Address - Phone:410-620-0602
Mailing Address - Fax:410-620-0477
Practice Address - Street 1:101 BIG ELK MALL
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-6035
Practice Address - Country:US
Practice Address - Phone:410-620-0602
Practice Address - Fax:410-620-0477
Is Sole Proprietor?:No
Enumeration Date:2016-03-19
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist