Provider Demographics
NPI:1407472954
Name:MCKEEHAN, MALLORY JO
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:JO
Last Name:MCKEEHAN
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 1:8060 S MASON MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-9597
Mailing Address - Country:US
Mailing Address - Phone:513-770-5587
Mailing Address - Fax:
Practice Address - Street 1:8060 S MASON MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-9597
Practice Address - Country:US
Practice Address - Phone:513-770-5587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-21
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03236977183500000X
KY019611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03236977OtherOHIO BOARD OF PHARMACY
KY019611OtherKENTUCKY BOARD OF PHARMACY