Provider Demographics
NPI:1093841108
Name:ZIMMERMAN, KENNETH MARK (BACHOLER OF PHARMACY)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MARK
Last Name:ZIMMERMAN
Suffix:
Gender:M
Credentials:BACHOLER OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 LEIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-2520
Mailing Address - Country:US
Mailing Address - Phone:863-682-0399
Mailing Address - Fax:
Practice Address - Street 1:2900 LAKELAND HIGHLANDS RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4379
Practice Address - Country:US
Practice Address - Phone:863-667-2711
Practice Address - Fax:863-667-1868
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0019320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103999700Medicaid
FL103999700Medicaid