1376524124 NPI number — DR. MACKENZIE PAULETTE WILSON PHARM.D.

Table of content: DR. MACKENZIE PAULETTE WILSON PHARM.D. (NPI 1376524124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376524124 NPI number — DR. MACKENZIE PAULETTE WILSON PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
MACKENZIE
Provider Middle Name:
PAULETTE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376524124
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HCR 61 BOX 30
Provider Second Line Business Mailing Address:
JCT HWY 160 & NR 35
Provider Business Mailing Address City Name:
TEEC NOS POS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86514-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-656-5000
Provider Business Mailing Address Fax Number:
928-656-5272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
JCT HWY 160 & NR 35
Provider Second Line Business Practice Location Address:
HCR 61
Provider Business Practice Location Address City Name:
TEEC NOS POS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86514-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-656-5000
Provider Business Practice Location Address Fax Number:
928-656-5272
Provider Enumeration Date:
11/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  13429 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 109MPW . This is a "NNMC" identifier . This identifiers is of the category "OTHER".




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