Provider Demographics
NPI:1447408307
Name:KENNEMER, DOUG
Entity Type:Individual
Prefix:
First Name:DOUG
Middle Name:
Last Name:KENNEMER
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 1:110 N OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-4946
Mailing Address - Country:US
Mailing Address - Phone:580-233-1202
Mailing Address - Fax:
Practice Address - Street 1:110 N OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-4946
Practice Address - Country:US
Practice Address - Phone:580-233-1202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8197183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist