Healthcare Provider Details

I. General information

NPI: 1689757965
Provider Name (Legal Business Name): MARTHA JEAN KENYON R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MARTHA JEAN BURKETT

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W SAGINAW ST
LANSING MI
48915-1925
US

IV. Provider business mailing address

13801 S HINMAN RD
EAGLE MI
48822-9657
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-7474
  • Fax: 517-364-7475
Mailing address:
  • Phone: 517-626-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302023528
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: