Provider Demographics
NPI:1972106979
Name:MACON, MICHAEL TRENT (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TRENT
Last Name:MACON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 BANDERA DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092-4525
Mailing Address - Country:US
Mailing Address - Phone:903-328-8770
Mailing Address - Fax:
Practice Address - Street 1:102 WALDRON DR
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-1902
Practice Address - Country:US
Practice Address - Phone:580-920-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57862183500000X
OK15613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist