Provider Demographics
NPI:1073660478
Name:MCKENZIE MANSFIELD PHARMACY SERVICES, LLC
Entity Type:Organization
Organization Name:MCKENZIE MANSFIELD PHARMACY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-297-3456
Mailing Address - Street 1:4825 ROCKBRIDGE RD
Mailing Address - Street 2:SUITES 5 & 6
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-4297
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4825 ROCKBRIDGE RD
Practice Address - Street 2:SUITES 5 & 6
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4297
Practice Address - Country:US
Practice Address - Phone:404-297-3456
Practice Address - Fax:404-297-4790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008733333600000X
GA3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4862500001Medicare ID - Type Unspecified