Provider Demographics
NPI:1588911176
Name:KENNEDY, DIANE MARIE (RPH)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 IRELAND AVE
Mailing Address - Street 2:PHARMACY DEPARTMENT
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-2722
Mailing Address - Country:US
Mailing Address - Phone:502-624-5915
Mailing Address - Fax:502-624-2095
Practice Address - Street 1:851 IRELAND AVE
Practice Address - Street 2:PHARMACY DEPARTMENT
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-2722
Practice Address - Country:US
Practice Address - Phone:502-624-5915
Practice Address - Fax:502-624-2095
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008407183500000X
NH2220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist