Provider Demographics
NPI:1477890168
Name:MCKENZIE, WESLEY DOUGLAS (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:DOUGLAS
Last Name:MCKENZIE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 NUNNALLY PL
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3625
Mailing Address - Country:US
Mailing Address - Phone:770-595-0665
Mailing Address - Fax:
Practice Address - Street 1:2500 MIRROR LAKE BLVD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180
Practice Address - Country:US
Practice Address - Phone:678-840-8788
Practice Address - Fax:678-840-8786
Is Sole Proprietor?:No
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist