Healthcare Provider Details

I. General information

NPI: 1497730105
Provider Name (Legal Business Name): KENNETH J FISHER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 CEDAR LN
UNIONVILLE CT
06085-1154
US

IV. Provider business mailing address

12 CEDAR LN
UNIONVILLE CT
06085-1154
US

V. Phone/Fax

Practice location:
  • Phone: 860-550-5831
  • Fax:
Mailing address:
  • Phone: 860-550-5831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPCT.0008096
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1835N0905X
TaxonomyNuclear Pharmacist
License NumberPCT.0008096
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: