Provider Demographics
NPI:1891075156
Name:ERICKSON, KENNETH ROBERT JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROBERT
Last Name:ERICKSON
Suffix:JR
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 1:2636 MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-6251
Mailing Address - Country:US
Mailing Address - Phone:540-907-7436
Mailing Address - Fax:
Practice Address - Street 1:2636 MOUNTAIN VIEW RD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-6251
Practice Address - Country:US
Practice Address - Phone:540-907-7436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204436183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist