Provider Demographics
NPI:1356622617
Name:ETU-MANTEY, KENNETH
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:ETU-MANTEY
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 1:7512 LEM TURNER RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-3353
Mailing Address - Country:US
Mailing Address - Phone:904-924-9019
Mailing Address - Fax:
Practice Address - Street 1:7512 LEM TURNER RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-3353
Practice Address - Country:US
Practice Address - Phone:904-924-9019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS40574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS40574OtherPHAR