Provider Demographics
NPI:1609503713
Name:BRACKMAN, MAKENNA
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:
Last Name:BRACKMAN
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 1:03949 FOREST LN N
Mailing Address - Street 2:
Mailing Address - City:NEW BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:45869-9621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:03949 FOREST LN N
Practice Address - Street 2:
Practice Address - City:NEW BREMEN
Practice Address - State:OH
Practice Address - Zip Code:45869-9621
Practice Address - Country:US
Practice Address - Phone:937-638-5381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03442068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist