Provider Demographics
NPI:1053628503
Name:ERNST, KENNETH ANDREW (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ANDREW
Last Name:ERNST
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 KINGSGATE RD
Mailing Address - Street 2:APT. E12
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2371
Mailing Address - Country:US
Mailing Address - Phone:801-652-6661
Mailing Address - Fax:
Practice Address - Street 1:17850 LOWER BOONES FERRY RD
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5228
Practice Address - Country:US
Practice Address - Phone:971-233-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH0012176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist