Provider Demographics
NPI:1447851779
Name:VAIDIAN, MAMMEN CHERIAN
Entity type:Individual
Prefix:
First Name:MAMMEN
Middle Name:CHERIAN
Last Name:VAIDIAN
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 1:3461 HORIZON BLVD
Mailing Address - Street 2:
Mailing Address - City:TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4967
Mailing Address - Country:US
Mailing Address - Phone:215-942-7483
Mailing Address - Fax:
Practice Address - Street 1:3461 HORIZON BLVD
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4967
Practice Address - Country:US
Practice Address - Phone:215-942-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP445190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist