Provider Demographics
NPI:1740596592
Name:HENDERSON, KENNETH ROBERTO
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERTO
Last Name:HENDERSON
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 1:10375 RICHMOND AVE
Mailing Address - Street 2:#1575
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-4143
Mailing Address - Country:US
Mailing Address - Phone:866-312-1177
Mailing Address - Fax:713-953-1925
Practice Address - Street 1:10375 RICHMOND AVE
Practice Address - Street 2:#1575
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-4143
Practice Address - Country:US
Practice Address - Phone:866-312-1177
Practice Address - Fax:713-953-1925
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX179826183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician