Healthcare Provider Details

I. General information

NPI: 1164014411
Provider Name (Legal Business Name): KENITRA KIAMA CHARLES CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KENITRA KIAMA PONTOON CPHT

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7360 SKIDAWAY RD
SAVANNAH GA
31406-4265
US

IV. Provider business mailing address

99 GATEWAY BLVD W UNIT 1431
SAVANNAH GA
31419-7541
US

V. Phone/Fax

Practice location:
  • Phone: 912-354-3816
  • Fax:
Mailing address:
  • Phone: 941-524-2272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPHTC057415
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: