Healthcare Provider Details

I. General information

NPI: 1821081076
Provider Name (Legal Business Name): JEFFREY D KENNICUTT PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 04/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S MANNING BLVD ST PETERS HOSPITAL PHARMACY DEPARTMENT
ALBANY NY
12208-1707
US

IV. Provider business mailing address

28 FIFE DR
SLINGERLANDS NY
12159-7208
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-1266
  • Fax: 518-525-6986
Mailing address:
  • Phone: 518-525-1266
  • Fax: 518-525-7673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberI032556-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: