Provider Demographics
NPI:1952685976
Name:WIDLE, KENT (RPH)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:WIDLE
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 1:105 VEST MILL CIR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2943
Mailing Address - Country:US
Mailing Address - Phone:336-718-7894
Mailing Address - Fax:336-718-7860
Practice Address - Street 1:105 VEST MILL CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2943
Practice Address - Country:US
Practice Address - Phone:336-718-7894
Practice Address - Fax:336-718-7860
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09269183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist