Provider Demographics
NPI:1376110486
Name:RICHARDSON, KENNETH JAQUEZ
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAQUEZ
Last Name:RICHARDSON
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 1:938 LILAC ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15217-2656
Mailing Address - Country:US
Mailing Address - Phone:706-951-4813
Mailing Address - Fax:
Practice Address - Street 1:3601 5TH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3403
Practice Address - Country:US
Practice Address - Phone:412-623-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPI123259183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician