Provider Demographics
NPI:1588117436
Name:MANGEAC, ELIZABETH (PHAMD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MANGEAC
Suffix:
Gender:F
Credentials:PHAMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S MIDDLETON RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8124
Mailing Address - Country:US
Mailing Address - Phone:208-546-3396
Mailing Address - Fax:
Practice Address - Street 1:175 S MIDDLETON RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-8124
Practice Address - Country:US
Practice Address - Phone:208-546-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7571183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist