Provider Demographics
NPI:1144239344
Name:HARRELSON, KENNETH DALE (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DALE
Last Name:HARRELSON
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 1:1213 OAK DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-3929
Mailing Address - Country:US
Mailing Address - Phone:662-494-4748
Mailing Address - Fax:662-494-2565
Practice Address - Street 1:504 WEST MAIN STREET
Practice Address - Street 2:STE 1
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-2759
Practice Address - Country:US
Practice Address - Phone:662-494-4748
Practice Address - Fax:662-494-2565
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE5522183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00091456Medicaid
MS2515483OtherMABP