Provider Demographics
NPI:1740945377
Name:KENNEDY, CALVIN
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:KENNEDY
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 1:79 ERWIN ST
Mailing Address - Street 2:
Mailing Address - City:PAINTED POST
Mailing Address - State:NY
Mailing Address - Zip Code:14870-9710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-2609
Practice Address - Country:US
Practice Address - Phone:607-733-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1446921OtherNABP E-PROFILE ID
NY068555OtherPHARMACIST LICENSE