Provider Demographics
NPI:1992072383
Name:PURDY, KENNETH
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:PURDY
Suffix:
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 1:12312 E SPRAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-0720
Mailing Address - Country:US
Mailing Address - Phone:509-921-0659
Mailing Address - Fax:509-921-2152
Practice Address - Street 1:12312 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-0720
Practice Address - Country:US
Practice Address - Phone:509-921-0659
Practice Address - Fax:509-921-2152
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00070553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist