Provider Demographics
NPI:1568933141
Name:SMITH, KENNETH (PHARMD, PHD, RPH)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHARMD, PHD, RPH
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD, PHD, RPH
Mailing Address - Street 1:4393 FIELDING LN
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-1647
Mailing Address - Country:US
Mailing Address - Phone:706-728-7239
Mailing Address - Fax:
Practice Address - Street 1:4393 FIELDING LN
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-1647
Practice Address - Country:US
Practice Address - Phone:706-728-7239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-08
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist