Provider Demographics
NPI:1134492481
Name:KENNEDY, ROBERT S
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR # DRIVE-QD
Mailing Address - Street 2:
Mailing Address - City:JBSA FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:405-833-4825
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR # DRIVE
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:405-833-4825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist