Healthcare Provider Details

I. General information

NPI: 1073660478
Provider Name (Legal Business Name): MCKENZIE MANSFIELD PHARMACY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 ROCKBRIDGE RD SUITES 5 & 6
STONE MOUNTAIN GA
30083-4297
US

IV. Provider business mailing address

4825 ROCKBRIDGE RD SUITES 5 & 6
STONE MOUNTAIN GA
30083-4297
US

V. Phone/Fax

Practice location:
  • Phone: 404-297-3456
  • Fax: 404-297-4790
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE008733
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. LUIS HARRIS
Title or Position: PHARMACIST
Credential:
Phone: 404-297-3456