Provider Demographics
NPI:1164014411
Name:CHARLES, KENITRA KIAMA (CPHT)
Entity Type:Individual
Prefix:
First Name:KENITRA
Middle Name:KIAMA
Last Name:CHARLES
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:KENITRA
Other - Middle Name:KIAMA
Other - Last Name:PONTOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPHT
Mailing Address - Street 1:99 GATEWAY BLVD W UNIT 1431
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-7541
Mailing Address - Country:US
Mailing Address - Phone:941-524-2272
Mailing Address - Fax:
Practice Address - Street 1:7360 SKIDAWAY RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4265
Practice Address - Country:US
Practice Address - Phone:912-354-3816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC057415183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician