Provider Demographics
NPI:1750596854
Name:MCKENZIE, MARK A (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:MCKENZIE
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 1:2026 TREYBROOK CT
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-4015
Mailing Address - Country:US
Mailing Address - Phone:636-464-4821
Mailing Address - Fax:
Practice Address - Street 1:190 PLAZA DR
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-1828
Practice Address - Country:US
Practice Address - Phone:573-883-3524
Practice Address - Fax:573-883-7991
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO40183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist