Provider Demographics
NPI:1366725806
Name:GRULKE, MACKENZIE (PHARMD)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:GRULKE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 W RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47306-0001
Mailing Address - Country:US
Mailing Address - Phone:989-306-0191
Mailing Address - Fax:
Practice Address - Street 1:2720 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-4635
Practice Address - Country:US
Practice Address - Phone:765-287-8533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023259A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist