Provider Demographics
NPI:1659046696
Name:KENNY, KREG
Entity Type:Individual
Prefix:
First Name:KREG
Middle Name:
Last Name:KENNY
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 1:30504 RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:NEW HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:48165-9695
Mailing Address - Country:US
Mailing Address - Phone:248-719-3142
Mailing Address - Fax:
Practice Address - Street 1:20401 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1999
Practice Address - Country:US
Practice Address - Phone:248-449-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53024135111835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy