Provider Demographics
NPI:1528650413
Name:DECKER, KENNETH LEE (PHARMD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:DECKER
Suffix:
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 1:408 9TH ST SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-4714
Mailing Address - Country:US
Mailing Address - Phone:330-454-2000
Mailing Address - Fax:
Practice Address - Street 1:408 9TH ST SW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-4714
Practice Address - Country:US
Practice Address - Phone:330-454-2000
Practice Address - Fax:234-521-7249
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034399481835P2201X, 1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0432477Medicaid