Provider Demographics
NPI:1801187216
Name:MANN, KENNETH T (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:T
Last Name:MANN
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 1:2990 CAMROSE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-1726
Mailing Address - Country:US
Mailing Address - Phone:541-607-9554
Mailing Address - Fax:
Practice Address - Street 1:2130 MARCOLA RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-2592
Practice Address - Country:US
Practice Address - Phone:541-747-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0009590183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0009590OtherSTATE PHARMACY LICENSE