Provider Demographics
NPI:1942366836
Name:WALKUP, KENNY RAY JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNY
Middle Name:RAY
Last Name:WALKUP
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:350 S LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1814
Mailing Address - Country:US
Mailing Address - Phone:248-446-2643
Mailing Address - Fax:248-486-1906
Practice Address - Street 1:350 S LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-1814
Practice Address - Country:US
Practice Address - Phone:248-446-2643
Practice Address - Fax:248-486-1906
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5302028789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist