Provider Demographics
NPI:1801126925
Name:HENDERSON, KNICKY S (RPH)
Entity type:Individual
Prefix:
First Name:KNICKY
Middle Name:S
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 W SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-4306
Mailing Address - Country:US
Mailing Address - Phone:602-283-2071
Mailing Address - Fax:602-283-2098
Practice Address - Street 1:3434 W SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-4306
Practice Address - Country:US
Practice Address - Phone:602-283-2071
Practice Address - Fax:602-283-2098
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist