Healthcare Provider Details

I. General information

NPI: 1003198797
Provider Name (Legal Business Name): MANDY RENEE FILLINGAME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 STERLINGTON RD
MONROE LA
71203-2513
US

IV. Provider business mailing address

2901 STERLINGTON RD
MONROE LA
71203-2513
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-0321
  • Fax:
Mailing address:
  • Phone: 318-323-0321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19118
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: