Provider Demographics
NPI:1609618966
Name:MACKLIN, LICAMIED CHALISE (PHARMD)
Entity type:Individual
Prefix:
First Name:LICAMIED
Middle Name:CHALISE
Last Name:MACKLIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 WOODSONG WAY
Mailing Address - Street 2:
Mailing Address - City:TERRY
Mailing Address - State:MS
Mailing Address - Zip Code:39170-8160
Mailing Address - Country:US
Mailing Address - Phone:601-260-2411
Mailing Address - Fax:
Practice Address - Street 1:2901 MONTOPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6411
Practice Address - Country:US
Practice Address - Phone:512-978-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-08
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist