Provider Demographics
NPI:1790007722
Name:GRANT, KENNETH MARK (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MARK
Last Name:GRANT
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 1:17577 MAXON LANE
Mailing Address - Street 2:
Mailing Address - City:ADAMS
Mailing Address - State:NY
Mailing Address - Zip Code:13605
Mailing Address - Country:US
Mailing Address - Phone:315-232-4562
Mailing Address - Fax:315-232-3705
Practice Address - Street 1:17577 MAXON LN
Practice Address - Street 2:
Practice Address - City:ADAMS
Practice Address - State:NY
Practice Address - Zip Code:13605-2127
Practice Address - Country:US
Practice Address - Phone:315-232-4562
Practice Address - Fax:315-232-3705
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist