Provider Demographics
NPI:1427383801
Name:CAMILLI, KENNETH RYAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RYAN
Last Name:CAMILLI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19631 W CATAWBA AVE
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4002
Mailing Address - Country:US
Mailing Address - Phone:704-895-1342
Mailing Address - Fax:704-895-1348
Practice Address - Street 1:19631 W CATAWBA AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4002
Practice Address - Country:US
Practice Address - Phone:704-895-1342
Practice Address - Fax:704-895-1348
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19515183500000X
MAPH233335183500000X
FLPS42958183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist