Provider Demographics
NPI:1194172585
Name:GEORGE, KENNETH (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GEORGE
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 1:8031 ABBEY RD
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-5383
Mailing Address - Country:US
Mailing Address - Phone:708-614-7556
Mailing Address - Fax:708-532-7391
Practice Address - Street 1:17113 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3369
Practice Address - Country:US
Practice Address - Phone:708-532-7335
Practice Address - Fax:708-532-7391
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL051036450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist