Provider Demographics
NPI:1154056125
Name:SANDERSON, KENNETH LEE JR (PHARMD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:SANDERSON
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:ARCHBALD
Mailing Address - State:PA
Mailing Address - Zip Code:18403-1985
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5927 RIDGE AVE # 59
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1667
Practice Address - Country:US
Practice Address - Phone:215-487-3419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP456771183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist