Provider Demographics
NPI:1154130037
Name:MANGOLD, JESS ALLAN (RPH)
Entity type:Individual
Prefix:
First Name:JESS
Middle Name:ALLAN
Last Name:MANGOLD
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 ROLAND ST
Mailing Address - Street 2:
Mailing Address - City:COMBINED LOCKS
Mailing Address - State:WI
Mailing Address - Zip Code:54113-1402
Mailing Address - Country:US
Mailing Address - Phone:920-570-8095
Mailing Address - Fax:
Practice Address - Street 1:644 ROLAND ST
Practice Address - Street 2:
Practice Address - City:COMBINED LOCKS
Practice Address - State:WI
Practice Address - Zip Code:54113-1402
Practice Address - Country:US
Practice Address - Phone:920-570-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14360-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist