Provider Demographics
NPI:1376524124
Name:WILSON, MACKENZIE PAULETTE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:PAULETTE
Last Name:WILSON
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:HCR 61 BOX 30
Mailing Address - Street 2:JCT HWY 160 & NR 35
Mailing Address - City:TEEC NOS POS
Mailing Address - State:AZ
Mailing Address - Zip Code:86514-0000
Mailing Address - Country:US
Mailing Address - Phone:928-656-5000
Mailing Address - Fax:928-656-5272
Practice Address - Street 1:JCT HWY 160 & NR 35
Practice Address - Street 2:HCR 61
Practice Address - City:TEEC NOS POS
Practice Address - State:AZ
Practice Address - Zip Code:86514-0000
Practice Address - Country:US
Practice Address - Phone:928-656-5000
Practice Address - Fax:928-656-5272
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
109MPWOtherNNMC