Provider Demographics
NPI:1265958730
Name:PAULISH, KENNETH PATRICK
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PATRICK
Last Name:PAULISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518
Mailing Address - Country:US
Mailing Address - Phone:570-885-6298
Mailing Address - Fax:
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-808-7706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP451662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist