Provider Demographics
NPI:1700184397
Name:CHAFFIN, KENNETH H (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:H
Last Name:CHAFFIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3637
Mailing Address - Country:US
Mailing Address - Phone:770-682-5512
Mailing Address - Fax:770-962-7626
Practice Address - Street 1:645 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3637
Practice Address - Country:US
Practice Address - Phone:770-682-5512
Practice Address - Fax:770-962-7626
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2012-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist