Provider Demographics
NPI:1437368651
Name:MMJM INC
Entity type:Organization
Organization Name:MMJM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-282-6046
Mailing Address - Street 1:19 DUNDAFF ST
Mailing Address - Street 2:2ND FLOOR STE
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-1828
Mailing Address - Country:US
Mailing Address - Phone:570-282-1080
Mailing Address - Fax:570-282-1815
Practice Address - Street 1:19 DUNDAFF ST
Practice Address - Street 2:2ND FLOOR STE
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-1828
Practice Address - Country:US
Practice Address - Phone:570-282-1080
Practice Address - Fax:570-282-1815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4817173336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2081860OtherPK
PA101902594Medicaid
5966110001Medicare NSC