Provider Demographics
NPI:1437690013
Name:MILLER, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MILLER
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 1:3700 OWEN RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-9193
Mailing Address - Country:US
Mailing Address - Phone:810-750-3735
Mailing Address - Fax:
Practice Address - Street 1:3700 OWEN RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-9193
Practice Address - Country:US
Practice Address - Phone:810-750-3735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist