Provider Demographics
NPI:1558837443
Name:AMAYO, KENNETH EDO
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDO
Last Name:AMAYO
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 1:330 E GREENE ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:GA
Mailing Address - Zip Code:31064-1012
Mailing Address - Country:US
Mailing Address - Phone:706-468-1666
Mailing Address - Fax:706-468-0782
Practice Address - Street 1:330 E GREENE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-1012
Practice Address - Country:US
Practice Address - Phone:706-468-1666
Practice Address - Fax:706-468-0782
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist