Healthcare Provider Details

I. General information

NPI: 1265523799
Provider Name (Legal Business Name): KENNETH EDWARD ARCHER, JR DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N MAIN ST
SWEETWATER TN
37874-2806
US

IV. Provider business mailing address

442 FAIRLANE DR
SWEETWATER TN
37874-1113
US

V. Phone/Fax

Practice location:
  • Phone: 423-337-5813
  • Fax: 423-337-3907
Mailing address:
  • Phone: 423-337-5813
  • Fax: 423-337-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5309
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: