Provider Demographics
NPI:1982997771
Name:MANSOUR, PETER N
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:N
Last Name:MANSOUR
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 1:1432 S MEEKER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3206
Mailing Address - Country:US
Mailing Address - Phone:626-665-7383
Mailing Address - Fax:
Practice Address - Street 1:1050 HUNTINGTON DR
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-2475
Practice Address - Country:US
Practice Address - Phone:626-803-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist