Provider Demographics
NPI:1497730105
Name:FISHER, KENNETH J (RPH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:FISHER
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 1:12 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:UNIONVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06085-1154
Mailing Address - Country:US
Mailing Address - Phone:860-550-5831
Mailing Address - Fax:
Practice Address - Street 1:12 CEDAR LN
Practice Address - Street 2:
Practice Address - City:UNIONVILLE
Practice Address - State:CT
Practice Address - Zip Code:06085-1154
Practice Address - Country:US
Practice Address - Phone:860-550-5831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0008096183500000X, 1835N0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N0905XPharmacy Service ProvidersPharmacistNuclear