Provider Demographics
NPI:1992113922
Name:BROWN, KENNETH (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 EMPIRE BLVD APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-3538
Mailing Address - Country:US
Mailing Address - Phone:646-474-4106
Mailing Address - Fax:
Practice Address - Street 1:2535 31ST AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-3607
Practice Address - Country:US
Practice Address - Phone:718-545-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02530321Medicaid
NY4352910001Medicare NSC