1568933141 NPI number — DR. KENNETH SMITH PHARMD, PHD, RPH

Table of content: DR. KENNETH SMITH PHARMD, PHD, RPH (NPI 1568933141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568933141 NPI number — DR. KENNETH SMITH PHARMD, PHD, RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KENNETH
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, PHD, RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
KENNETH
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMD, PHD, RPH
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1568933141
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4393 FIELDING LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30092-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-728-7239
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4393 FIELDING LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORCROSS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30092-1647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-728-7239
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2018

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:  RPH030758 , 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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