Provider Demographics
NPI:1306115571
Name:HEARN, KENNETH L (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:HEARN
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 1:5802 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2659
Mailing Address - Country:US
Mailing Address - Phone:804-288-3191
Mailing Address - Fax:804-288-3134
Practice Address - Street 1:5802 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2659
Practice Address - Country:US
Practice Address - Phone:804-288-3191
Practice Address - Fax:804-288-3134
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-17
Last Update Date:2011-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202005487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202005487OtherCOMMONWEALTH OF VIRGINA DEPARTMENT OF HEALTH PROFESSIONS