MEDICARE: MCKENZIE MARIE MATHISON PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RPH033200	GA

General Provider Information

NPI Number	:	1417576786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZIE MARIE MATHISON PHARMD

Provider Business Mailing Address
First Line	:	229 WASHINGTON BLVD
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30132-9088
Country	:	US
Telephone Number	:	770-686-4245
Fax Number	:

Provider Business Practice Location Address
First Line	:	51 E PAULDING DR
Second Line	:
City	:	DALLAS
State	:	GA
Zip	:	30157-7190
Country	:	US
Telephone Number	:	770-686-4245
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2020
Last Update Date	:	08/30/2021

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