Provider Demographics
NPI:1578678512
Name:WILLIAM KENNEDY
Entity Type:Organization
Organization Name:WILLIAM KENNEDY
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-645-3588
Mailing Address - Street 1:28 W RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LANSFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18232-1330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28 W RIDGE ST
Practice Address - Street 2:
Practice Address - City:LANSFORD
Practice Address - State:PA
Practice Address - Zip Code:18232-1330
Practice Address - Country:US
Practice Address - Phone:570-645-3588
Practice Address - Fax:570-645-7253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415330L333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3973496OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA1007450860001Medicaid
PABT5587108OtherDEA #
3973496OtherOTHER ID NUMBER-COMMERCIAL NUMBER