Provider Demographics
NPI:1427052844
Name:MACKENZIES PHARMACY INC
Entity type:Organization
Organization Name:MACKENZIES PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTELLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:203-261-2541
Mailing Address - Street 1:19 BLACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3981
Mailing Address - Country:US
Mailing Address - Phone:203-261-2541
Mailing Address - Fax:
Practice Address - Street 1:930 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4550
Practice Address - Country:US
Practice Address - Phone:203-261-2541
Practice Address - Fax:203-268-5836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CT2083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004032504Medicaid
0709785OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0645850001Medicare NSC