Healthcare Provider Details

I. General information

NPI: 1689274771
Provider Name (Legal Business Name): GEORGE EDWARD MACKINNON III PHD, RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

8618 222ND CT
SALEM WI
53168-9077
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-7476
  • Fax:
Mailing address:
  • Phone: 262-843-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11236
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: