Provider Demographics
NPI:1467168617
Name:KUALLENY, MENA
Entity Type:Individual
Prefix:
First Name:MENA
Middle Name:
Last Name:KUALLENY
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 1:2913 CHESTERFIELD AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1159
Mailing Address - Country:US
Mailing Address - Phone:304-444-3286
Mailing Address - Fax:
Practice Address - Street 1:2201 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2843
Practice Address - Country:US
Practice Address - Phone:606-408-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY023111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist