Provider Demographics
NPI:1790190122
Name:WATSON, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WATSON
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 1:2414 LAKE PARK RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-1342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 GLADES RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1355
Practice Address - Country:US
Practice Address - Phone:859-986-3103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017112183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist