Provider Demographics
NPI:1578553723
Name:MCKENZIE DRUGS & COMPOUNDING CENTER INC
Entity Type:Organization
Organization Name:MCKENZIE DRUGS & COMPOUNDING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:770-972-6050
Mailing Address - Street 1:4814 HWY 78 STE 10
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-4649
Mailing Address - Country:US
Mailing Address - Phone:770-972-6050
Mailing Address - Fax:770-972-6051
Practice Address - Street 1:4814 HWY 78 STE 10
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-4649
Practice Address - Country:US
Practice Address - Phone:770-972-6050
Practice Address - Fax:770-972-6051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5212333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000157858AMedicaid
GA000157858AMedicaid