Provider Demographics
NPI:1245750942
Name:KENNEDY, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 S EUFAULA AVE
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:AL
Mailing Address - Zip Code:36027-4406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3176 S EUFAULA AVE
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:AL
Practice Address - Zip Code:36027-4406
Practice Address - Country:US
Practice Address - Phone:334-687-2338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13873183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL13873OtherSTATE LICENSE