Provider Demographics
NPI:1508848235
Name:SOUDER, KENNETH GENE (DPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GENE
Last Name:SOUDER
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 1:1525 ROBIN HOOD LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3702
Mailing Address - Country:US
Mailing Address - Phone:423-360-3679
Mailing Address - Fax:423-283-4198
Practice Address - Street 1:402 BEMBERG RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2938
Practice Address - Country:US
Practice Address - Phone:423-543-3493
Practice Address - Fax:423-534-5493
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist