Provider Demographics
NPI:1861419574
Name:WILLIAM C KENNEDY
Entity type:Organization
Organization Name:WILLIAM C KENNEDY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-668-6366
Mailing Address - Street 1:56 MAUCH CHUNK ST
Mailing Address - Street 2:
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-1405
Mailing Address - Country:US
Mailing Address - Phone:570-668-6366
Mailing Address - Fax:570-668-9019
Practice Address - Street 1:56 MAUCH CHUNK ST
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-1405
Practice Address - Country:US
Practice Address - Phone:570-668-6366
Practice Address - Fax:570-668-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410693L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007450860002Medicaid
3937046OtherNCPDP
PAPP410693LOtherSTATE LIC NUMBER
PAAT7802728OtherDEA NUMBER
PA1007450860002Medicaid