Healthcare Provider Details

I. General information

NPI: 1700841079
Provider Name (Legal Business Name): MANGHAM RX DRUGS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LOUISIANA ST
MANGHAM LA
71259
US

IV. Provider business mailing address

PO BOX 207
MANGHAM LA
71259-0207
US

V. Phone/Fax

Practice location:
  • Phone: 318-248-2345
  • Fax: 318-248-3651
Mailing address:
  • Phone: 318-248-2345
  • Fax: 318-248-3651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number4311
License Number StateLA

VIII. Authorized Official

Name: DAVID P GIBSON
Title or Position: PRES
Credential: RPH
Phone: 318-248-2345