Healthcare Provider Details

I. General information

NPI: 1912246083
Provider Name (Legal Business Name): KENNETH LAZENBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 ELKINS DR
MORGANTOWN WV
26505-2891
US

IV. Provider business mailing address

1007 ELKINS DR
MORGANTOWN WV
26505-2891
US

V. Phone/Fax

Practice location:
  • Phone: 304-319-3939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP0007103
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: