Provider Demographics
NPI:1255674164
Name:STARK, KENNETH RICHARD (PHARMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RICHARD
Last Name:STARK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10555 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1436
Mailing Address - Country:US
Mailing Address - Phone:208-321-2669
Mailing Address - Fax:
Practice Address - Street 1:10555 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1436
Practice Address - Country:US
Practice Address - Phone:208-321-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6643183500000X
IDCS18944183500000X
UT6035703-1701183500000X
UT6035703-8911183500000X
AZS019112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist