Provider Demographics
NPI:1881252773
Name:BETHEA, KENNETH ALAN (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:BETHEA
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 1:335 WOODPECKER PT
Mailing Address - Street 2:
Mailing Address - City:DANIELSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30633-5235
Mailing Address - Country:US
Mailing Address - Phone:229-460-0177
Mailing Address - Fax:
Practice Address - Street 1:18 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-1740
Practice Address - Country:US
Practice Address - Phone:706-283-8228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist