=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700175544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH MATTHEW HOUDYSCHELL PHARMD.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2011
-----------------------------------------------------
Last Update Date | 04/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 PARK AVE
-----------------------------------------------------
City | IRONTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45638-1544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-532-5550
-----------------------------------------------------
Fax | 740-534-0513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 PARK AVENUE
-----------------------------------------------------
City | IRONTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45638-1544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-532-5550
-----------------------------------------------------
Fax | 740-534-0513
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 013188
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP0006592
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03230396
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------