Healthcare Provider Details

I. General information

NPI: 1033013057
Provider Name (Legal Business Name): KENNETH HARRIS II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3112 COUNTRY MEADOW RD
ANTIOCH TN
37013-1210
US

IV. Provider business mailing address

3112 COUNTRY MEADOW RD
ANTIOCH TN
37013-1210
US

V. Phone/Fax

Practice location:
  • Phone: 901-330-7230
  • Fax:
Mailing address:
  • Phone: 901-330-7230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number50016
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: