Provider Demographics
NPI:1619968237
Name:MANGUM, STACY ALLEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ALLEN
Last Name:MANGUM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 CHAUTAUQUA LN
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1929
Mailing Address - Country:US
Mailing Address - Phone:573-624-9657
Mailing Address - Fax:573-624-6265
Practice Address - Street 1:1200 N ONE MILE RD
Practice Address - Street 2:MISSOURI SOUTHERN HEALTHCARE
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1000
Practice Address - Country:US
Practice Address - Phone:573-614-1957
Practice Address - Fax:573-624-6265
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0447331835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy