Provider Demographics
NPI:1508047515
Name:MANTEI, KENNETH EDWARD (RPH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:EDWARD
Last Name:MANTEI
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 1:1 WATERMAN AVE
Mailing Address - Street 2:PO BOX 375
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732
Mailing Address - Country:US
Mailing Address - Phone:607-624-5012
Mailing Address - Fax:
Practice Address - Street 1:119 W. 2ND
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901
Practice Address - Country:US
Practice Address - Phone:607-733-5202
Practice Address - Fax:607-733-5202
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031822L183500000X
PA30345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist