Provider Demographics
NPI:1205599040
Name:WALTERS, MACKENZIE LAUREN (RPH)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LAUREN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ROSTRAVER TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15012-9614
Mailing Address - Country:US
Mailing Address - Phone:724-550-5612
Mailing Address - Fax:
Practice Address - Street 1:100 WILLIAM MARKS DRIVE
Practice Address - Street 2:
Practice Address - City:MUNHALL
Practice Address - State:PA
Practice Address - Zip Code:15120
Practice Address - Country:US
Practice Address - Phone:412-461-4699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP456189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist