Provider Demographics
NPI:1114203296
Name:MACKINNON, MARILYN MARY
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:MARY
Last Name:MACKINNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589
Mailing Address - Country:US
Mailing Address - Phone:608-873-7612
Mailing Address - Fax:608-873-7894
Practice Address - Street 1:1705 HIGHWAY FIFTY ONE
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589
Practice Address - Country:US
Practice Address - Phone:608-873-7612
Practice Address - Fax:608-873-7894
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14888-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist