=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932689643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH A ROCKWELL JR. PHARMD, MS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2018
-----------------------------------------------------
Last Update Date | 08/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 SPRUCE ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-4238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-349-8817
-----------------------------------------------------
Fax | 215-349-5132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 TAYLOR AVE
-----------------------------------------------------
City | WOODLYN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19094-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-574-0875
-----------------------------------------------------
Fax | 484-472-1530
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP041316R
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------