Provider Demographics
NPI:1013734110
Name:WASHINGTON, KENNEDY
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 PAPER WOODS DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5366
Mailing Address - Country:US
Mailing Address - Phone:404-438-8118
Mailing Address - Fax:
Practice Address - Street 1:455 GRAYSON HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7171
Practice Address - Country:US
Practice Address - Phone:770-962-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-21
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH035156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist