Healthcare Provider Details

I. General information

NPI: 1508148891
Provider Name (Legal Business Name): KACI BOULWARE KENON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 ROYAL DR
ALPHARETTA GA
30022-2475
US

IV. Provider business mailing address

1124 WILLOW CREST WAY
AUSTELL GA
30168-5734
US

V. Phone/Fax

Practice location:
  • Phone: 678-715-2578
  • Fax:
Mailing address:
  • Phone: 305-528-0270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH020323
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: