Provider Demographics
NPI:1184907529
Name:MANSURI, ALTAF (PHARM D)
Entity type:Individual
Prefix:
First Name:ALTAF
Middle Name:
Last Name:MANSURI
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 ALTAMONT RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-4025
Mailing Address - Country:US
Mailing Address - Phone:732-910-6500
Mailing Address - Fax:
Practice Address - Street 1:129 SOMERSET ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2814
Practice Address - Country:US
Practice Address - Phone:908-725-8259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI032893001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI03289300OtherNJ BOARD OF PHARMACY