Provider Demographics
NPI:1235411919
Name:GAUTHIER, KENNETH JAMES
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JAMES
Last Name:GAUTHIER
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 1:4282 VINEYARD TRL
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-6197
Mailing Address - Country:US
Mailing Address - Phone:770-972-8310
Mailing Address - Fax:
Practice Address - Street 1:1783 HIGHWAY 138 SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1295
Practice Address - Country:US
Practice Address - Phone:770-483-5644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist