Provider Demographics
NPI:1396083275
Name:EKISS, KEN P (PD)
Entity type:Individual
Prefix:MR
First Name:KEN
Middle Name:P
Last Name:EKISS
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1978 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:985-873-1246
Mailing Address - Fax:985-873-1760
Practice Address - Street 1:1978 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-873-1246
Practice Address - Fax:985-873-1760
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15330183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist