Provider Demographics
NPI:1376833749
Name:MCMILLEN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MCMILLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-1911
Mailing Address - Country:US
Mailing Address - Phone:502-239-6160
Mailing Address - Fax:502-239-7970
Practice Address - Street 1:5601 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-1911
Practice Address - Country:US
Practice Address - Phone:502-239-6160
Practice Address - Fax:502-239-7970
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist