1962856732 NPI number — TIMOTHY KENNEDY

Table of content: JACKY TRUONG PHARMACIST (NPI 1073221990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962856732 NPI number — TIMOTHY KENNEDY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENNEDY
Provider First Name:
TIMOTHY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962856732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 SOMERBY DR APT 1507
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36695-5442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-554-4174
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6701 AIRPROT BLVD
Provider Second Line Business Practice Location Address:
STE A101
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-633-8880
Provider Business Practice Location Address Fax Number:
251-378-6222
Provider Enumeration Date:
04/19/2016

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: 207R00000X , with the licence number:  36695 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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