Provider Demographics
NPI:1811908015
Name:JM MANCUSO INC
Entity type:Organization
Organization Name:JM MANCUSO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-282-3033
Mailing Address - Street 1:24 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-1973
Mailing Address - Country:US
Mailing Address - Phone:570-282-3033
Mailing Address - Fax:570-282-7354
Practice Address - Street 1:24 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-1973
Practice Address - Country:US
Practice Address - Phone:570-282-3033
Practice Address - Fax:570-282-7354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412523L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty