Provider Demographics
NPI:1700980760
Name:KENCO INC
Entity Type:Organization
Organization Name:KENCO INC
Other - Org Name:COUNTRY MARKET PHARMACY #11
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHARMACY OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:517-789-8980
Mailing Address - Street 1:1821 SPRING ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-2703
Mailing Address - Country:US
Mailing Address - Phone:517-787-6081
Mailing Address - Fax:517-787-0160
Practice Address - Street 1:1535 W MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1805
Practice Address - Country:US
Practice Address - Phone:517-265-9162
Practice Address - Fax:517-266-1455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010077863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2044382OtherPK
MI2359506Medicaid