Provider Demographics
NPI:1063565927
Name:MANTUA PHARMACY INC
Entity type:Organization
Organization Name:MANTUA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIGGERS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-274-2209
Mailing Address - Street 1:10870 N. MAIN ST
Mailing Address - Street 2:PO BOX 777
Mailing Address - City:MANTUA
Mailing Address - State:OH
Mailing Address - Zip Code:44255
Mailing Address - Country:US
Mailing Address - Phone:330-274-2209
Mailing Address - Fax:330-274-5220
Practice Address - Street 1:10870 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:OH
Practice Address - Zip Code:44255
Practice Address - Country:US
Practice Address - Phone:330-274-2209
Practice Address - Fax:330-274-5220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5492800Medicaid
OH5492800Medicaid
OH0854320001Medicare NSC