Provider Demographics
NPI:1083180715
Name:MASTRONARDI-MORRIS, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:MASTRONARDI-MORRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43121 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5005
Mailing Address - Country:US
Mailing Address - Phone:248-499-7840
Mailing Address - Fax:248-481-9523
Practice Address - Street 1:43121 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5005
Practice Address - Country:US
Practice Address - Phone:248-499-7840
Practice Address - Fax:248-481-9523
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-20
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010094513336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy