Provider Demographics
NPI:1811279201
Name:MANTENA, REENA CHENNA (PHARMD)
Entity type:Individual
Prefix:
First Name:REENA
Middle Name:CHENNA
Last Name:MANTENA
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 1:4339 DIPAOLO CENTER
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025
Mailing Address - Country:US
Mailing Address - Phone:847-257-4832
Mailing Address - Fax:847-299-1943
Practice Address - Street 1:4339 DIPAOLO CENTER
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-5202
Practice Address - Country:US
Practice Address - Phone:847-257-4832
Practice Address - Fax:847-299-1943
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-286409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist