Healthcare Provider Details

I. General information

NPI: 1427383801
Provider Name (Legal Business Name): KENNETH RYAN CAMILLI PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19631 W CATAWBA AVE
CORNELIUS NC
28031-4002
US

IV. Provider business mailing address

19631 W CATAWBA AVE
CORNELIUS NC
28031-4002
US

V. Phone/Fax

Practice location:
  • Phone: 704-895-1342
  • Fax: 704-895-1348
Mailing address:
  • Phone: 704-895-1342
  • Fax: 704-895-1348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19515
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH233335
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS42958
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: