Provider Demographics
NPI:1265757223
Name:SEGRETO, KENNETH BREAUX (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:BREAUX
Last Name:SEGRETO
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 1:141 HANNAFORD SQ # 2
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1653
Mailing Address - Country:US
Mailing Address - Phone:802-442-3642
Mailing Address - Fax:802-442-3065
Practice Address - Street 1:141 HANNAFORD SQ # 2
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1653
Practice Address - Country:US
Practice Address - Phone:802-442-3642
Practice Address - Fax:802-442-3065
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033-0003660183500000X
NY54252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY183500000XMedicaid
VT183500000XMedicaid