Provider Demographics
NPI:1548583735
Name:MANCINI, ALICIA CAMILLE (RPH)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:CAMILLE
Last Name:MANCINI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13723 N LITCHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-4268
Mailing Address - Country:US
Mailing Address - Phone:623-255-3208
Mailing Address - Fax:
Practice Address - Street 1:13723 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-4268
Practice Address - Country:US
Practice Address - Phone:623-255-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049187183500000X
AZS021034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02959259Medicaid