Provider Demographics
NPI:1316380025
Name:MACKEY, ANDREA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MACKEY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GRAND AVE BLDG 27
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93407-9000
Mailing Address - Country:US
Mailing Address - Phone:805-756-5260
Mailing Address - Fax:805-756-7001
Practice Address - Street 1:1 GRAND AVE BLDG 27
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93407-9000
Practice Address - Country:US
Practice Address - Phone:805-756-5260
Practice Address - Fax:805-756-7001
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51752183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51752OtherCALIFORNIA PHARMACIST LICENSE