Provider Demographics
NPI:1376749325
Name:PETTENGILL, KENNETH JAMES (RPH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:PETTENGILL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140360
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32614-0360
Mailing Address - Country:US
Mailing Address - Phone:352-317-2731
Mailing Address - Fax:
Practice Address - Street 1:1210 SW 33RD AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-2853
Practice Address - Country:US
Practice Address - Phone:352-622-2913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS27736183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist