Provider Demographics
NPI:1558644369
Name:HAVEN, KWAME KENYATTA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KWAME
Middle Name:KENYATTA
Last Name:HAVEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 NORTH BURNSIDE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737
Mailing Address - Country:US
Mailing Address - Phone:225-200-0164
Mailing Address - Fax:
Practice Address - Street 1:1624 N BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2139
Practice Address - Country:US
Practice Address - Phone:225-644-7528
Practice Address - Fax:225-647-3949
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA18547183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist