Provider Demographics
NPI:1548542160
Name:MANTECON, CARL E SR (RPH)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:E
Last Name:MANTECON
Suffix:SR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3743
Mailing Address - Country:US
Mailing Address - Phone:850-265-0499
Mailing Address - Fax:850-265-6563
Practice Address - Street 1:1402 OHIO AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-3743
Practice Address - Country:US
Practice Address - Phone:850-265-0499
Practice Address - Fax:850-268-6563
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-10
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH25901183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist