=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073679684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KLH ENTERPRISES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/28/2006
-----------------------------------------------------
Last Update Date | 09/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N OAKLEY DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31906-4476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-685-1845
-----------------------------------------------------
Fax | 706-685-9066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 N OAKLEY DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31906-4476
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-685-1845
-----------------------------------------------------
Fax | 706-685-9066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KENNETH LYDELL HARRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-685-1845
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHRE008778
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------