Provider Demographics
NPI:1699329540
Name:MANTOHAC, GREVELYN KRISTINE
Entity type:Individual
Prefix:
First Name:GREVELYN KRISTINE
Middle Name:
Last Name:MANTOHAC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4490 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-3240
Mailing Address - Country:US
Mailing Address - Phone:956-542-3891
Mailing Address - Fax:
Practice Address - Street 1:4490 E 14TH ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-3240
Practice Address - Country:US
Practice Address - Phone:956-542-3891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008935183500000X
AZS023942183500000X
TX63390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist