Provider Demographics
NPI:1376145383
Name:HENDERSON, KAMMI MIGNON (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:KAMMI
Middle Name:MIGNON
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 BROAD CREEK LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-9146
Mailing Address - Country:US
Mailing Address - Phone:904-476-4289
Mailing Address - Fax:
Practice Address - Street 1:9218 S, FL-228
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063
Practice Address - Country:US
Practice Address - Phone:904-259-3860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36881183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist