Provider Demographics
NPI:1205933140
Name:MAC'S PHARMACY AT BROWN'S CREEK, LLC
Entity type:Organization
Organization Name:MAC'S PHARMACY AT BROWN'S CREEK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILHOLT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:865-806-6453
Mailing Address - Street 1:1612 E. LAMAR ALEXANDER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804
Mailing Address - Country:US
Mailing Address - Phone:865-982-7162
Mailing Address - Fax:865-977-4263
Practice Address - Street 1:1612 E. LAMAR ALEXANDER PARKWAY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804
Practice Address - Country:US
Practice Address - Phone:865-982-7162
Practice Address - Fax:865-977-4263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000006643336C0003X
3336C0003X, 332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2088358OtherPK
TN9440097Medicaid
TN1452244Medicaid