Provider Demographics
NPI:1255772372
Name:TENNESSEN, KENNETH RUSSELL (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RUSSELL
Last Name:TENNESSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-7629
Mailing Address - Country:US
Mailing Address - Phone:920-206-9585
Mailing Address - Fax:920-206-9702
Practice Address - Street 1:301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-7629
Practice Address - Country:US
Practice Address - Phone:920-206-9585
Practice Address - Fax:920-206-9702
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17098-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist