Provider Demographics
NPI:1689368490
Name:COLEMAN, KENT DWAYNE
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:DWAYNE
Last Name:COLEMAN
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 1:319 E EATON ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-1806
Mailing Address - Country:US
Mailing Address - Phone:731-200-9050
Mailing Address - Fax:
Practice Address - Street 1:319 E EATON ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-1806
Practice Address - Country:US
Practice Address - Phone:731-200-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist