Healthcare Provider Details

I. General information

NPI: 1205599040
Provider Name (Legal Business Name): MACKENZIE LAUREN WALTERS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 10/19/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WILLIAM MARKS DRIVE
MUNHALL PA
15120
US

IV. Provider business mailing address

122 VALLEY VIEW DR
ROSTRAVER TOWNSHIP PA
15012-9614
US

V. Phone/Fax

Practice location:
  • Phone: 412-461-4699
  • Fax:
Mailing address:
  • Phone: 724-550-5612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP456189
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: