Provider Demographics
NPI:1316421498
Name:JENNINGS, ROBERT KELLY
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:KELLY
Last Name:JENNINGS
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 1:8599 HIGHLANDS TRCE
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-3815
Mailing Address - Country:US
Mailing Address - Phone:205-629-6303
Mailing Address - Fax:
Practice Address - Street 1:140 COUNCIL DR
Practice Address - Street 2:
Practice Address - City:ODENVILLE
Practice Address - State:AL
Practice Address - Zip Code:35120-4495
Practice Address - Country:US
Practice Address - Phone:205-629-6303
Practice Address - Fax:205-629-6357
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL14968OtherALABAMA PHARMACY LICENSE