Provider Demographics
NPI:1184635674
Name:JOHN D MANUELE & BANJAMIN C LEON
Entity type:Organization
Organization Name:JOHN D MANUELE & BANJAMIN C LEON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-738-8800
Mailing Address - Street 1:1620 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-4962
Mailing Address - Country:US
Mailing Address - Phone:559-738-8800
Mailing Address - Fax:559-733-2636
Practice Address - Street 1:1620 S COURT ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-4962
Practice Address - Country:US
Practice Address - Phone:559-738-8800
Practice Address - Fax:559-733-2636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY398633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPMA367840Medicaid
2005149OtherPK
2005149OtherPK
CAPMA367840Medicaid