Provider Demographics
NPI:1447715628
Name:MANDRELL, GERALD MATTHEW (RPH)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:MATTHEW
Last Name:MANDRELL
Suffix:
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 1:1911 CHOWKEEBIN CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-5870
Mailing Address - Country:US
Mailing Address - Phone:850-322-5313
Mailing Address - Fax:
Practice Address - Street 1:1950 COMMONWEALTH LN
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-3196
Practice Address - Country:US
Practice Address - Phone:850-504-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS18142183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist