Provider Demographics
NPI:1497343081
Name:DELAY, KENNETH JACKSON (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JACKSON
Last Name:DELAY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 EAST WINTHROPE AVE
Mailing Address - Street 2:
Mailing Address - City:MILLEN
Mailing Address - State:GA
Mailing Address - Zip Code:30442
Mailing Address - Country:US
Mailing Address - Phone:478-494-0032
Mailing Address - Fax:478-982-1010
Practice Address - Street 1:936 EAST WINTHROPE AVE
Practice Address - Street 2:
Practice Address - City:MILLEN
Practice Address - State:GA
Practice Address - Zip Code:30442
Practice Address - Country:US
Practice Address - Phone:478-494-0032
Practice Address - Fax:478-982-1010
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH13801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty