Provider Demographics
NPI:1164704219
Name:HOLDEN, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HOLDEN
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 1:18457 HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-6747
Mailing Address - Country:US
Mailing Address - Phone:985-974-2118
Mailing Address - Fax:
Practice Address - Street 1:345 W RAILROAD AVE
Practice Address - Street 2:PAUL'S PHARMACY
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443
Practice Address - Country:US
Practice Address - Phone:985-809-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist