Provider Demographics
NPI:1265523799
Name:ARCHER, JR, KENNETH EDWARD (DPH)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:EDWARD
Last Name:ARCHER, JR
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 FAIRLANE DR
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1113
Mailing Address - Country:US
Mailing Address - Phone:423-337-5813
Mailing Address - Fax:423-337-3907
Practice Address - Street 1:207 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-2806
Practice Address - Country:US
Practice Address - Phone:423-337-5813
Practice Address - Fax:423-337-3907
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist