Provider Demographics
NPI:1356717169
Name:MANZO, GARY
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:MANZO
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 1:28 MOUNT HUNGER SHORE RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5662
Mailing Address - Country:US
Mailing Address - Phone:207-721-0990
Mailing Address - Fax:207-721-0662
Practice Address - Street 1:28 MOUNT HUNGER SHORE RD
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5662
Practice Address - Country:US
Practice Address - Phone:207-721-0990
Practice Address - Fax:207-721-0662
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR3982183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist