Provider Demographics
NPI:1982086849
Name:MAMANGUN, MACARIO
Entity Type:Individual
Prefix:
First Name:MACARIO
Middle Name:
Last Name:MAMANGUN
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 1:17400 DRAKE ST
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-1883
Mailing Address - Country:US
Mailing Address - Phone:714-325-3456
Mailing Address - Fax:714-792-0949
Practice Address - Street 1:1930 N PLACENTIA AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1522
Practice Address - Country:US
Practice Address - Phone:714-792-0975
Practice Address - Fax:714-792-0949
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist