1700211778 NPI number — KENNETH WILLIAM TAYLOR PHARMD.

Table of content: KENNETH WILLIAM TAYLOR PHARMD. (NPI 1700211778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700211778 NPI number — KENNETH WILLIAM TAYLOR PHARMD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAYLOR
Provider First Name:
KENNETH
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
KENNY
Provider Other Middle Name:
WILLIAM
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1700211778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
139 SUNSET RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30263-7705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-463-9664
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3055 HIGHWAY 34 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-2179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-252-3937
Provider Business Practice Location Address Fax Number:
770-304-3593
Provider Enumeration Date:
09/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH027473 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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