Provider Demographics
NPI:1174061048
Name:FUQUA, KENNETH WEBSTER SR (RPH;CPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WEBSTER
Last Name:FUQUA
Suffix:SR
Gender:M
Credentials:RPH;CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 OLD POLK CITY RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-6622
Mailing Address - Country:US
Mailing Address - Phone:863-858-2828
Mailing Address - Fax:
Practice Address - Street 1:1122 OLD POLK CITY RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-6622
Practice Address - Country:US
Practice Address - Phone:863-858-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPU001021835G0303X
FLPS113291835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric