Provider Demographics
NPI:1093351488
Name:MANTANONA, AUDREY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:
Last Name:MANTANONA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5195
Mailing Address - Country:US
Mailing Address - Phone:253-477-5101
Mailing Address - Fax:
Practice Address - Street 1:500 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5195
Practice Address - Country:US
Practice Address - Phone:360-477-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH.60946512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist