Provider Demographics
NPI:1700176872
Name:MANITPISITKUL, WANA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:WANA
Middle Name:
Last Name:MANITPISITKUL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4960 WALKING STICK RD
Mailing Address - Street 2:APT H
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-8058
Mailing Address - Country:US
Mailing Address - Phone:410-328-9701
Mailing Address - Fax:
Practice Address - Street 1:4960 WALKING STICK RD
Practice Address - Street 2:APT H
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-8058
Practice Address - Country:US
Practice Address - Phone:410-328-9701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD177871835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist