Healthcare Provider Details

I. General information

NPI: 1184968455
Provider Name (Legal Business Name): KJK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7723 CLEARVIEW CHURCH LN
LYLES TN
37098-1674
US

IV. Provider business mailing address

7723 CLEARVIEW CHURCH LN
LYLES TN
37098-1674
US

V. Phone/Fax

Practice location:
  • Phone: 931-670-6035
  • Fax: 931-670-6399
Mailing address:
  • Phone: 931-670-6035
  • Fax: 931-670-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1530
License Number StateTN

VIII. Authorized Official

Name: CHRISTOPHER KONECNY
Title or Position: CFO
Credential: PHARMD
Phone: 732-580-5805