Provider Demographics
NPI:1629588330
Name:NOSAL, KENNETH J (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:NOSAL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CTR
Mailing Address - State:CT
Mailing Address - Zip Code:06250-0515
Mailing Address - Country:US
Mailing Address - Phone:860-456-1358
Mailing Address - Fax:860-456-1384
Practice Address - Street 1:141B STORRS RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD CTR
Practice Address - State:CT
Practice Address - Zip Code:06250-1638
Practice Address - Country:US
Practice Address - Phone:860-456-1358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-08
Last Update Date:2017-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5392183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist