Healthcare Provider Details

I. General information

NPI: 1104998897
Provider Name (Legal Business Name): PAUL D MANGINO PHARMD, BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S JACKSON ST
LOUISVILLE KY
40202-1675
US

IV. Provider business mailing address

530 S JACKSON ST
LOUISVILLE KY
40202-1675
US

V. Phone/Fax

Practice location:
  • Phone: 502-562-3165
  • Fax: 502-561-3655
Mailing address:
  • Phone: 502-562-3165
  • Fax: 502-561-3655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number7106
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: