Provider Demographics
NPI:1669896247
Name:MCKAY, JOHN BRIAN (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BRIAN
Last Name:MCKAY
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 1:1604 E SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9489
Mailing Address - Country:US
Mailing Address - Phone:575-359-3435
Mailing Address - Fax:575-359-3213
Practice Address - Street 1:1604 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-9489
Practice Address - Country:US
Practice Address - Phone:575-359-3435
Practice Address - Fax:575-359-3213
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00006131183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist