Healthcare Provider Details

I. General information

NPI: 1700160785
Provider Name (Legal Business Name): RICHARD MENGONI R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8011 VENTURA ST NE
ALBUQUERQUE NM
87109-6429
US

IV. Provider business mailing address

6620 HIGH RIDGE PL NE
ALBUQUERQUE NM
87111-8174
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-2860
  • Fax: 505-217-2866
Mailing address:
  • Phone: 913-634-8435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12569
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4360
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number044650
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: