Provider Demographics
NPI:1639861248
Name:MONGOLD, COLEN HUNTER
Entity Type:Individual
Prefix:
First Name:COLEN
Middle Name:HUNTER
Last Name:MONGOLD
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 1:117 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-9566
Mailing Address - Country:US
Mailing Address - Phone:304-257-1026
Mailing Address - Fax:304-257-9622
Practice Address - Street 1:117 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-9566
Practice Address - Country:US
Practice Address - Phone:304-257-1026
Practice Address - Fax:304-257-9622
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0008159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist