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General NPI Number Information
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NPI Number | 1053930420
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Entity Type | Individual
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Provider Name | MOLLY MARIE KETRON PHARMD
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Gender | Female
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Dates
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Enumeration Date | 04/15/2020
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Last Update Date | 04/15/2020
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Provider Practice Location Address
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Address Line | 5104 BOBBY HICKS HWY
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City | JOHNSON CITY
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State | TN
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Zip | 37615-6217
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Country | US
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Telephone | 423-477-3372
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Fax |
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Provider Business Mailing Address
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Address Line | 2112 MALVERN CT
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City | KINGSPORT
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State | TN
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Zip | 37660-5084
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Country | US
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Telephone | 423-306-1407
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 0202217047
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 42260
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License Number State | TN
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