Provider Demographics
NPI:1376049338
Name:POWELL, KENNETH RAYMOND (PD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAYMOND
Last Name:POWELL
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 COUNTY ROAD 751
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-2105
Mailing Address - Country:US
Mailing Address - Phone:870-243-0700
Mailing Address - Fax:
Practice Address - Street 1:1112 WINDOVER RD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6038
Practice Address - Country:US
Practice Address - Phone:870-935-6364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD06310183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist