Basic Information
Provider Information | |||||||||
NPI: | 1902475437 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TENKKU | ||||||||
FirstName: | MACKENZIE | ||||||||
MiddleName: | HORNING | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3741 ONEIDA ST | ||||||||
Address2: |   | ||||||||
City: | STOW | ||||||||
State: | OH | ||||||||
PostalCode: | 442244214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3307523714 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1320 MERCY DR NW | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447082614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304891000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2021 | ||||||||
LastUpdateDate: | 06/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 3151327 | OH | N |   | Pharmacy Service Providers | Pharmacist | Pharmacotherapy | 183500000X | 03233894 | OH | Y |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.