Healthcare Provider Details

I. General information

NPI: 1821609587
Provider Name (Legal Business Name): MACKENZIE WATKINS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 06/19/2021
Certification Date: 06/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 WOLFRUM RD
WELDON SPRING MO
63304-7625
US

IV. Provider business mailing address

1003 WOLFRUM RD
WELDON SPRING MO
63304-7625
US

V. Phone/Fax

Practice location:
  • Phone: 636-300-0158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2019031419
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: