=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013471010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNISON PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2019
-----------------------------------------------------
Last Update Date | 04/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4050 BUFORD DRIVE
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-288-9798
-----------------------------------------------------
Fax | 678-288-9839
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 PINEHURST VIEW DRIVE
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-789-0048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST IN CHARGE
-----------------------------------------------------
Name | KENNETH AMANKWAH KWARTENG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-789-0048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336H0001X
-----------------------------------------------------
Taxonomy Name | Home Infusion Therapy Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------