Provider Demographics
NPI:1316558646
Name:MANSOUR, ANDREW (RPH)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 MORAGA RD
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-2211
Mailing Address - Country:US
Mailing Address - Phone:925-631-0204
Mailing Address - Fax:
Practice Address - Street 1:580 MORAGA RD
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556-2211
Practice Address - Country:US
Practice Address - Phone:925-631-0204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA824471835P1200X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy