Provider Demographics
NPI:1396122826
Name:EATON, KENNETH JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:EATON
Suffix:JR
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 1:75 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUCKSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04416-4025
Mailing Address - Country:US
Mailing Address - Phone:207-469-7030
Mailing Address - Fax:207-469-7035
Practice Address - Street 1:75 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416-4025
Practice Address - Country:US
Practice Address - Phone:207-469-7030
Practice Address - Fax:207-469-7035
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR3737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist