Provider Demographics
NPI:1568067577
Name:ROSS, KENNEDY D (RPH)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:D
Last Name:ROSS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 BISHOPS GATE APT B
Mailing Address - Street 2:
Mailing Address - City:GUILDERLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12084-9487
Mailing Address - Country:US
Mailing Address - Phone:518-944-9249
Mailing Address - Fax:
Practice Address - Street 1:260 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1123
Practice Address - Country:US
Practice Address - Phone:518-439-9356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist