Healthcare Provider Details

I. General information

NPI: 1710539200
Provider Name (Legal Business Name): SILAS MOGONDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9011 RENNER BLVD APT 2901
LENEXA KS
66219-3027
US

IV. Provider business mailing address

8701 JOHNSON DR
MERRIAM KS
66202-2150
US

V. Phone/Fax

Practice location:
  • Phone: 913-963-8670
  • Fax:
Mailing address:
  • Phone: 913-789-9275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number1-106833
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: