Provider Demographics
NPI:1851714695
Name:MASSENGILL, JAMES KENNETH (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KENNETH
Last Name:MASSENGILL
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 1:1115 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3228
Mailing Address - Country:US
Mailing Address - Phone:307-632-9111
Mailing Address - Fax:307-432-2590
Practice Address - Street 1:1115 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3228
Practice Address - Country:US
Practice Address - Phone:307-632-9111
Practice Address - Fax:307-432-2590
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2771183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist