Provider Demographics
NPI:1215302922
Name:DHAMI, MANGAL
Entity type:Individual
Prefix:
First Name:MANGAL
Middle Name:
Last Name:DHAMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1877 GROSSE POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-6723
Mailing Address - Country:US
Mailing Address - Phone:630-745-1692
Mailing Address - Fax:
Practice Address - Street 1:1877 GROSSE POINTE CIRCLE
Practice Address - Street 2:
Practice Address - City:HANOVE PARK
Practice Address - State:IL
Practice Address - Zip Code:60133
Practice Address - Country:US
Practice Address - Phone:630-745-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60609752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist