Provider Demographics
NPI:1619211075
Name:ANDERSON, JOHN KENNETH (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KENNETH
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1763 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02905-3532
Mailing Address - Country:US
Mailing Address - Phone:401-461-6770
Mailing Address - Fax:401-461-3925
Practice Address - Street 1:1763 BROAD ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02905-3532
Practice Address - Country:US
Practice Address - Phone:401-461-6770
Practice Address - Fax:401-461-3925
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRPH05172183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist