Provider Demographics
NPI:1720587900
Name:MCKENZIE, CODY
Entity Type:Individual
Prefix:
First Name:CODY
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 1:102 5TH AVE APT 2-203
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-8603
Mailing Address - Country:US
Mailing Address - Phone:253-426-8528
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-580-3012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6050331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist