=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497343081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH JACKSON DELAY RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2021
-----------------------------------------------------
Last Update Date | 01/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 936 EAST WINTHROPE AVE
-----------------------------------------------------
City | MILLEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-494-0032
-----------------------------------------------------
Fax | 478-982-1010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 936 EAST WINTHROPE AVE
-----------------------------------------------------
City | MILLEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-494-0032
-----------------------------------------------------
Fax | 478-982-1010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH13801
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------