Provider Demographics
NPI:1982042198
Name:COLLINS, KENNERH PROVINE (BS)
Entity Type:Individual
Prefix:MR
First Name:KENNERH
Middle Name:PROVINE
Last Name:COLLINS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 56TH COURT
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305
Mailing Address - Country:US
Mailing Address - Phone:601-604-9114
Mailing Address - Fax:
Practice Address - Street 1:2917 56TH COURT
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305
Practice Address - Country:US
Practice Address - Phone:601-604-9114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE70521835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSE7052OtherMISSISSIPPI PHARMACY LICENSE