Provider Demographics
NPI:1457617953
Name:MACKELLAR, DON
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:
Last Name:MACKELLAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W 4TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2077
Mailing Address - Country:US
Mailing Address - Phone:951-657-9511
Mailing Address - Fax:
Practice Address - Street 1:540 W 4TH ST STE 1
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2077
Practice Address - Country:US
Practice Address - Phone:951-657-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist