MEDICARE: KENNETH RYAN CAMILLI PHARM.D.

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	19515	NC
2	183500000X	Pharmacist	PH233335	MA
3	183500000X	Pharmacist	PS42958	FL

General Provider Information

NPI Number	:	1427383801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH RYAN CAMILLI PHARM.D.

Provider Business Mailing Address
First Line	:	19631 W CATAWBA AVE
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-4002
Country	:	US
Telephone Number	:	704-895-1342
Fax Number	:	704-895-1348

Provider Business Practice Location Address
First Line	:	19631 W CATAWBA AVE
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-4002
Country	:	US
Telephone Number	:	704-895-1342
Fax Number	:	704-895-1348

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

Provider Enumeration Date	:	10/02/2009
Last Update Date	:	04/07/2011

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