Provider Demographics
NPI:1841680428
Name:MCKENNA-MANTICA, JAMES KENNETH (PHARM D, RPH)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:KENNETH
Last Name:MCKENNA-MANTICA
Suffix:
Gender:M
Credentials:PHARM D, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1604
Mailing Address - Country:US
Mailing Address - Phone:518-292-1250
Mailing Address - Fax:
Practice Address - Street 1:709 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1604
Practice Address - Country:US
Practice Address - Phone:518-292-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059979183500000X
VT033.0096278183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY059979OtherNYS PHARMACIST LICENSE NUMBER
VT033.0096278OtherVT PHARMACIST LICENSE NUMBER