Provider Demographics
NPI:1215532544
Name:ISHAM, KENNETH JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:ISHAM
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 1:109 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-2110
Mailing Address - Country:US
Mailing Address - Phone:706-595-6666
Mailing Address - Fax:706-597-7023
Practice Address - Street 1:109 W HILL ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2110
Practice Address - Country:US
Practice Address - Phone:706-595-6666
Practice Address - Fax:706-597-7023
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist