Provider Demographics
NPI:1851674618
Name:INGRAM, JOHN KENNETH (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:KENNETH
Last Name:INGRAM
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 1:385 HARLAN RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-2000
Mailing Address - Country:US
Mailing Address - Phone:770-262-1868
Mailing Address - Fax:
Practice Address - Street 1:9591 CONNERS RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180
Practice Address - Country:US
Practice Address - Phone:770-456-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist