Provider Demographics
NPI:1760499198
Name:DAVIS, KENNETH JAMES (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JAMES
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 DOYLE ST W
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-2314
Mailing Address - Country:US
Mailing Address - Phone:706-886-7422
Mailing Address - Fax:
Practice Address - Street 1:326 DOYLE ST W
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-2314
Practice Address - Country:US
Practice Address - Phone:706-886-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA09035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA09035OtherPHARMACY LICENCE NUMBER