Provider Demographics
NPI:1194745232
Name:MCKENNEY, KERRY JON
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:JON
Last Name:MCKENNEY
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 1:2185 WILLOUGHBY RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-9419
Mailing Address - Country:US
Mailing Address - Phone:517-322-8018
Mailing Address - Fax:517-322-8242
Practice Address - Street 1:1401 S CREYTS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8507
Practice Address - Country:US
Practice Address - Phone:517-322-8018
Practice Address - Fax:517-322-8242
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302024420183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist