Provider Demographics
NPI:1699040600
Name:KENNON, WILLIAM LEE (RPH)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:LEE
Last Name:KENNON
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 1:2655 SHASTA WAY
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4455
Mailing Address - Country:US
Mailing Address - Phone:541-884-1780
Mailing Address - Fax:
Practice Address - Street 1:2655 SHASTA WAY
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4455
Practice Address - Country:US
Practice Address - Phone:541-884-1780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH0008597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist