MEDICARE: MR. KENNETH DALE HARRELSON RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	E5522	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2515483	OTHER	MS	MABP

General Provider Information

NPI Number	:	1144239344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH DALE HARRELSON RPH

Provider Business Mailing Address
First Line	:	1213 OAK DRIVE
Second Line	:
City	:	WEST POINT
State	:	MS
Zip	:	39773-3929
Country	:	US
Telephone Number	:	662-494-4748
Fax Number	:	662-494-2565

Provider Business Practice Location Address
First Line	:	504 WEST MAIN STREET
Second Line	:	STE 1
City	:	WEST POINT
State	:	MS
Zip	:	39773-2759
Country	:	US
Telephone Number	:	662-494-4748
Fax Number	:	662-494-2565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	07/08/2007

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