=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073295028
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAVANAUGHRX LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2023
-----------------------------------------------------
Last Update Date | 08/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5200 KAVANAUGH BLVD
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72207-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-664-3844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 KAVANAUGH BLVD
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72207-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-664-3844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. KENNY HARRISON
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 501-580-1895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------