Provider Demographics
NPI:1700841079
Name:MANGHAM RX DRUGS, INC
Entity Type:Organization
Organization Name:MANGHAM RX DRUGS, INC
Other - Org Name:MANGHAM RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:318-248-2345
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:
Mailing Address - City:MANGHAM
Mailing Address - State:LA
Mailing Address - Zip Code:71259-0207
Mailing Address - Country:US
Mailing Address - Phone:318-248-2345
Mailing Address - Fax:318-248-3651
Practice Address - Street 1:104 LOUISIANA ST
Practice Address - Street 2:
Practice Address - City:MANGHAM
Practice Address - State:LA
Practice Address - Zip Code:71259
Practice Address - Country:US
Practice Address - Phone:318-248-2345
Practice Address - Fax:318-248-3651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA43113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1267422Medicaid
LAWBJS813OtherCCR
LA1919616OtherNCPDP
LA4311OtherPHARMACY STATE ID
LABM6489822OtherDEA
LAWBJS813OtherCCR
LA4311OtherPHARMACY STATE ID