Provider Demographics
NPI:1093097156
Name:SUE, KENNETH HENRY (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:HENRY
Last Name:SUE
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 1:2300 OTIS DR
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5722
Mailing Address - Country:US
Mailing Address - Phone:510-523-7043
Mailing Address - Fax:510-523-7021
Practice Address - Street 1:2300 OTIS DR
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5722
Practice Address - Country:US
Practice Address - Phone:510-523-7043
Practice Address - Fax:510-523-7021
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA30391183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA361924025OtherPHARMACIST
CA361924025Medicaid