Provider Demographics
NPI:1003169749
Name:FOSSO, KEVIN ANTHONY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
Last Name:FOSSO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 KIRKLEVINGTON DR
Mailing Address - Street 2:APT 89
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-2444
Mailing Address - Country:US
Mailing Address - Phone:859-523-0987
Mailing Address - Fax:
Practice Address - Street 1:3051 KIRKLEVINGTON DR
Practice Address - Street 2:APT 89
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-2422
Practice Address - Country:US
Practice Address - Phone:859-523-0987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist