Provider Demographics
NPI:1417562059
Name:BAIN, KENNETH NOEL
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:NOEL
Last Name:BAIN
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 1:1002 SHADOWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-1312
Mailing Address - Country:US
Mailing Address - Phone:318-465-1167
Mailing Address - Fax:903-938-3097
Practice Address - Street 1:207 E END BLVD N
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-3603
Practice Address - Country:US
Practice Address - Phone:903-938-3096
Practice Address - Fax:903-938-3097
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist