Provider Demographics
NPI:1689757965
Name:KENYON, MARTHA JEAN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:JEAN
Last Name:KENYON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:MARTHA
Other - Middle Name:JEAN
Other - Last Name:BURKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13801 S HINMAN RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:MI
Mailing Address - Zip Code:48822-9657
Mailing Address - Country:US
Mailing Address - Phone:517-626-2257
Mailing Address - Fax:
Practice Address - Street 1:1100 W SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-1925
Practice Address - Country:US
Practice Address - Phone:517-364-7474
Practice Address - Fax:517-364-7475
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023528183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist