Provider Demographics
NPI:1588235741
Name:SANTOS, KENNETH (CPHT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SANTOS
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 FOX HILL DR # 21-11
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5204
Mailing Address - Country:US
Mailing Address - Phone:248-972-7199
Mailing Address - Fax:
Practice Address - Street 1:602 W BROAD ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8658
Practice Address - Country:US
Practice Address - Phone:810-735-1341
Practice Address - Fax:810-735-4191
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303011948183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty