Provider Demographics
NPI:1154835122
Name:MACKS NUTRITION LLC
Entity Type:Organization
Organization Name:MACKS NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:RD
Authorized Official - Phone:973-768-0442
Mailing Address - Street 1:114 PINE ST
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-1539
Mailing Address - Country:US
Mailing Address - Phone:973-768-0442
Mailing Address - Fax:
Practice Address - Street 1:114 PINE ST
Practice Address - Street 2:
Practice Address - City:POMPTON LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07442-1539
Practice Address - Country:US
Practice Address - Phone:973-768-0442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86043468133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty