Provider Demographics
NPI:1053496513
Name:MANGOLD, TRACI ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:ANN
Last Name:MANGOLD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 CLARENCE LANE CT
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-2003
Mailing Address - Country:US
Mailing Address - Phone:716-741-1138
Mailing Address - Fax:
Practice Address - Street 1:60 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-2115
Practice Address - Country:US
Practice Address - Phone:716-684-7584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038959183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist