Provider Demographics
NPI:1073391918
Name:SMITH, MACKENZIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAIN ST NE APT 325
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-3515
Mailing Address - Country:US
Mailing Address - Phone:505-219-7891
Mailing Address - Fax:
Practice Address - Street 1:711 KASOTA AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-2842
Practice Address - Country:US
Practice Address - Phone:612-538-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist