Provider Demographics
NPI:1316567621
Name:MILLER, MCKNZY DEANNA
Entity Type:Individual
Prefix:
First Name:MCKNZY
Middle Name:DEANNA
Last Name:MILLER
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 1:1515 BLOOMHARDT RD
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98577-9670
Mailing Address - Country:US
Mailing Address - Phone:360-581-3289
Mailing Address - Fax:
Practice Address - Street 1:5201 CAPITOL BLVD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4418
Practice Address - Country:US
Practice Address - Phone:360-943-4043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60754024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist