Provider Demographics
NPI:1649514035
Name:MANGLER, KELLY L (PHARMD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MANGLER
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 1:2030 ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543
Mailing Address - Country:US
Mailing Address - Phone:630-554-4005
Mailing Address - Fax:630-383-7164
Practice Address - Street 1:2030 ROUTE 34
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543
Practice Address - Country:US
Practice Address - Phone:630-554-4005
Practice Address - Fax:630-383-7164
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist