Provider Demographics
NPI:1922661263
Name:MCKENZIE, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MCKENZIE
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 1:8613 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-1852
Mailing Address - Country:US
Mailing Address - Phone:402-451-2125
Mailing Address - Fax:402-451-2401
Practice Address - Street 1:8613 N 30TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-1852
Practice Address - Country:US
Practice Address - Phone:402-451-2125
Practice Address - Fax:402-451-2401
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23519183500000X
NE13668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist