Healthcare Provider Details

I. General information

NPI: 1376110486
Provider Name (Legal Business Name): KENNETH JAQUEZ RICHARDSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

2010 N BREVARD ST APT 635
CHARLOTTE NC
28206-3948
US

V. Phone/Fax

Practice location:
  • Phone: 980-488-5336
  • Fax: 704-316-2270
Mailing address:
  • Phone: 706-951-4813
  • Fax: 704-316-2270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number34259
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number700651
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: