Provider Demographics
NPI:1356653786
Name:MANGUM, DARRELL
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:MANGUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 BRIARPARK DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-5205
Mailing Address - Country:US
Mailing Address - Phone:713-268-3630
Mailing Address - Fax:623-869-1717
Practice Address - Street 1:3535 N BELT LINE RD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-7804
Practice Address - Country:US
Practice Address - Phone:972-255-7166
Practice Address - Fax:972-252-8140
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist