Provider Demographics
NPI:1477851210
Name:BURNETTE, KENNETH W
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:W
Last Name:BURNETTE
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 1:865 N COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-2076
Mailing Address - Country:US
Mailing Address - Phone:770-748-6490
Mailing Address - Fax:
Practice Address - Street 1:633 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2359
Practice Address - Country:US
Practice Address - Phone:770-748-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH011293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist