Healthcare Provider Details

I. General information

NPI: 1497145346
Provider Name (Legal Business Name): NATHAN KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 S PATTERSON BLVD STE 110
DAYTON OH
45402-2643
US

IV. Provider business mailing address

213 HOWARD ST
WAVERLY NY
14892-1519
US

V. Phone/Fax

Practice location:
  • Phone: 937-424-1440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP449125
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: