Provider Demographics
NPI:1598376675
Name:KENNEDY, NICKALAUS CRAIG
Entity Type:Individual
Prefix:
First Name:NICKALAUS
Middle Name:CRAIG
Last Name:KENNEDY
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 1:1349 E REPUBLIC RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7204
Mailing Address - Country:US
Mailing Address - Phone:417-887-9451
Mailing Address - Fax:417-877-0674
Practice Address - Street 1:1349 E REPUBLIC RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7204
Practice Address - Country:US
Practice Address - Phone:417-887-9451
Practice Address - Fax:417-877-0674
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019030619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist