Provider Demographics
NPI:1689903544
Name:MCKENZIE, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:MCKENZIE
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 1:1610 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:TX
Mailing Address - Zip Code:76574-3054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-3054
Practice Address - Country:US
Practice Address - Phone:512-352-3469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47210183500000X
AL14841183500000X
NC16846183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist