Healthcare Provider Details

I. General information

NPI: 1376524124
Provider Name (Legal Business Name): MACKENZIE PAULETTE WILSON PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JCT HWY 160 & NR 35 HCR 61
TEEC NOS POS AZ
86514-0000
US

IV. Provider business mailing address

HCR 61 BOX 30 JCT HWY 160 & NR 35
TEEC NOS POS AZ
86514-0000
US

V. Phone/Fax

Practice location:
  • Phone: 928-656-5000
  • Fax: 928-656-5272
Mailing address:
  • Phone: 928-656-5000
  • Fax: 928-656-5272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13429
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: