Provider Demographics
NPI:1982280251
Name:MANGRAM, SHADESHA S (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:SHADESHA
Middle Name:S
Last Name:MANGRAM
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 S HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-6408
Mailing Address - Country:US
Mailing Address - Phone:850-968-3388
Mailing Address - Fax:
Practice Address - Street 1:312 E NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-2737
Practice Address - Country:US
Practice Address - Phone:850-478-7488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist