Provider Demographics
NPI:1164902995
Name:GRAHAM, MCKENZIE ANN (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:ANN
Other - Last Name:HELLBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:418 W PERSHING AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2428
Mailing Address - Country:US
Mailing Address - Phone:307-331-8892
Mailing Address - Fax:
Practice Address - Street 1:845 N FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-857-6023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY4056OtherWYOMING BOARD OF PHARMACY IMMUNIZER LICENSE
WY4056OtherWYOMING BOARD OF PHARMACY