Provider Demographics
NPI:1568670743
Name:ADDY, KENNETH ALAN
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:ADDY
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 1:40 OAK LAKE PL
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-8975
Mailing Address - Country:US
Mailing Address - Phone:334-709-4106
Mailing Address - Fax:
Practice Address - Street 1:2185 REEVES ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2349
Practice Address - Country:US
Practice Address - Phone:334-794-0623
Practice Address - Fax:334-794-9526
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist