Provider Demographics
NPI:1336453984
Name:MACK, QUTINA S (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:QUTINA
Middle Name:S
Last Name:MACK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10104 SENATE DR
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4392
Mailing Address - Country:US
Mailing Address - Phone:708-218-6695
Mailing Address - Fax:
Practice Address - Street 1:1310 SOUTHERN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4623
Practice Address - Country:US
Practice Address - Phone:202-574-6748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19646183500000X
DCPH1000007461835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No183500000XPharmacy Service ProvidersPharmacist