Provider Demographics
NPI:1063812956
Name:MARTIN, MACKENZIE MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:MARIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 HALLTOWN RD
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-8448
Mailing Address - Country:US
Mailing Address - Phone:570-279-1991
Mailing Address - Fax:
Practice Address - Street 1:1 MILLBROOK PLZ
Practice Address - Street 2:
Practice Address - City:MILL HALL
Practice Address - State:PA
Practice Address - Zip Code:17751-1911
Practice Address - Country:US
Practice Address - Phone:570-748-6775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP439507183500000X
PARPI003633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist