Provider Demographics
NPI:1821781113
Name:WOODALL, KENNETH SCOTT (PHARMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:SCOTT
Last Name:WOODALL
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 1:23056 E CAMINA BUENA VIS
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-1325
Mailing Address - Country:US
Mailing Address - Phone:513-403-3170
Mailing Address - Fax:
Practice Address - Street 1:23056 E CAMINA BUENA VIS
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-1325
Practice Address - Country:US
Practice Address - Phone:513-403-3170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY017803183500000X
OH03334886183500000X
AZS023277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist