Healthcare Provider Details

I. General information

NPI: 1720682206
Provider Name (Legal Business Name): MICHELLE RENEE GWINN-MACKEY RPH, PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 JASON PL
CHATHAM IL
62629-2018
US

IV. Provider business mailing address

1099 JASON PL
CHATHAM IL
62629-2018
US

V. Phone/Fax

Practice location:
  • Phone: 217-483-2496
  • Fax: 217-483-5772
Mailing address:
  • Phone: 217-483-2496
  • Fax: 217-483-5772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-286073
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: