Provider Demographics
NPI:1356065254
Name:RIVES, KENNEDY SHEA
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:SHEA
Last Name:RIVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 ROUTE 146
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-3861
Mailing Address - Country:US
Mailing Address - Phone:518-371-3700
Mailing Address - Fax:518-371-7103
Practice Address - Street 1:839 ROUTE 146
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-3861
Practice Address - Country:US
Practice Address - Phone:518-371-3700
Practice Address - Fax:518-371-7103
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0134779183500000X
NY067976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist