Provider Demographics
NPI:1174645899
Name:MANGUAL, MADELINE (LIC 002465)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:
Last Name:MANGUAL
Suffix:
Gender:F
Credentials:LIC 002465
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE ORQUIDEA #300
Mailing Address - Street 2:CIVDAD APERDIN
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-276-6162
Mailing Address - Fax:787-876-0558
Practice Address - Street 1:CALLE AUTONOMIA #71
Practice Address - Street 2:FARMACIA SAN ANTONIO
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-876-2705
Practice Address - Fax:787-876-0558
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR002465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist