Provider Demographics
NPI:1821574823
Name:MCKENZIE, JEROLD A
Entity Type:Individual
Prefix:
First Name:JEROLD
Middle Name:A
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 1:4860 HONONEGAH RD
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-7777
Mailing Address - Country:US
Mailing Address - Phone:815-623-7798
Mailing Address - Fax:815-623-9479
Practice Address - Street 1:4860 HONONEGAH RD
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7777
Practice Address - Country:US
Practice Address - Phone:815-623-7798
Practice Address - Fax:815-623-9479
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.039948333600000X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No333600000XSuppliersPharmacy