Healthcare Provider Details

I. General information

NPI: 1174061048
Provider Name (Legal Business Name): KENNETH WEBSTER FUQUA SR. RPH;CPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 OLD POLK CITY RD
LAKELAND FL
33809-6622
US

IV. Provider business mailing address

1122 OLD POLK CITY RD
LAKELAND FL
33809-6622
US

V. Phone/Fax

Practice location:
  • Phone: 863-858-2828
  • Fax:
Mailing address:
  • Phone: 863-858-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberPU00102
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPS11329
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: