Healthcare Provider Details

I. General information

NPI: 1992296339
Provider Name (Legal Business Name): KENNESAW RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2851 COBB PKWY NW STE 107
KENNESAW GA
30152-2718
US

IV. Provider business mailing address

2851 COBB PKWY NW STE 107
KENNESAW GA
30152-2718
US

V. Phone/Fax

Practice location:
  • Phone: 700-800-0025
  • Fax: 770-800-0325
Mailing address:
  • Phone: 770-800-0025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE010626
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RITESH PATEL
Title or Position: PHARMACY MANAGER
Credential:
Phone: 770-800-0025