Provider Demographics
NPI:1871193060
Name:SIMMONS, KENNETH ROY
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROY
Last Name:SIMMONS
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 1:202 KITTY HAWK CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8581
Mailing Address - Country:US
Mailing Address - Phone:601-454-2257
Mailing Address - Fax:601-992-0231
Practice Address - Street 1:5341 HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6173
Practice Address - Country:US
Practice Address - Phone:601-992-8144
Practice Address - Fax:601-992-0231
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE07578183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist