Provider Demographics
NPI:1962736835
Name:KENNEDY, JOHN LOWRY (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:LOWRY
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-6020
Mailing Address - Country:US
Mailing Address - Phone:704-873-6297
Mailing Address - Fax:
Practice Address - Street 1:1716 E BROAD ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-4306
Practice Address - Country:US
Practice Address - Phone:704-872-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0496603Medicaid