=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346861853
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACKENZIE MAE MCGRAW CPHT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2020
-----------------------------------------------------
Last Update Date | 05/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 177 ERIE BLVD
-----------------------------------------------------
City | SUSQUEHANNA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18847-2791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-853-0901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 MURPHY LN
-----------------------------------------------------
City | NEWARK VALLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13811-4752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-778-9557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number | 30032403
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------