Provider Demographics
NPI:1821081076
Name:KENNICUTT, JEFFREY D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:KENNICUTT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 FIFE DR
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-7208
Mailing Address - Country:US
Mailing Address - Phone:518-525-1266
Mailing Address - Fax:518-525-7673
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:ST PETERS HOSPITAL PHARMACY DEPARTMENT
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1266
Practice Address - Fax:518-525-6986
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI032556-11835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist