Provider Demographics
NPI:1447563309
Name:STEWART, KENNETH THOMAS (DPH)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:THOMAS
Last Name:STEWART
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2471 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38108-3318
Mailing Address - Country:US
Mailing Address - Phone:901-454-1615
Mailing Address - Fax:901-454-4908
Practice Address - Street 1:2471 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38108-3318
Practice Address - Country:US
Practice Address - Phone:901-454-1615
Practice Address - Fax:901-454-4908
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNC540183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist