Provider Demographics
NPI:1720683329
Name:MCKENNA, MARY TERESE (RPH)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:TERESE
Last Name:MCKENNA
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 1:53 WARMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-3227
Mailing Address - Country:US
Mailing Address - Phone:401-864-7703
Mailing Address - Fax:
Practice Address - Street 1:681 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-3220
Practice Address - Country:US
Practice Address - Phone:401-943-7186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI02389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist