Provider Demographics
NPI:1699052795
Name:MANSERGH, KATHRYN DEANNE (RPH)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DEANNE
Last Name:MANSERGH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 ROUND LAKE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5003
Mailing Address - Country:US
Mailing Address - Phone:763-252-0751
Mailing Address - Fax:763-255-0757
Practice Address - Street 1:8000 BASS LAKE RD
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3118
Practice Address - Country:US
Practice Address - Phone:763-531-5005
Practice Address - Fax:763-531-5061
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist