Provider Demographics
NPI:1013122316
Name:OVERHOLT, KENNETH MARSHALL JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MARSHALL
Last Name:OVERHOLT
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 1:4619 MAHONING AVE NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-1418
Mailing Address - Country:US
Mailing Address - Phone:330-847-8000
Mailing Address - Fax:330-847-7708
Practice Address - Street 1:4619 MAHONING AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-1418
Practice Address - Country:US
Practice Address - Phone:330-847-8000
Practice Address - Fax:330-847-7708
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-13266183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist