Provider Demographics
NPI:1184099624
Name:MCKENNA, MICHAEL JAMES (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45600 UTICA PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5917
Mailing Address - Country:US
Mailing Address - Phone:586-739-5472
Mailing Address - Fax:586-739-5489
Practice Address - Street 1:45600 UTICA PARK BLVD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48315-5917
Practice Address - Country:US
Practice Address - Phone:586-739-5472
Practice Address - Fax:586-739-5489
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026010183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist