Provider Demographics
NPI:1871854737
Name:MAHN, ERICA LYNN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNN
Last Name:MAHN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 W KEARNEY ST STE 116
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-2055
Mailing Address - Country:US
Mailing Address - Phone:417-865-1547
Mailing Address - Fax:
Practice Address - Street 1:2650 W KEARNEY ST STE 116
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2055
Practice Address - Country:US
Practice Address - Phone:417-865-1547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012014970183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist