Provider Demographics
NPI:1144869967
Name:KENNEDY, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:KENNEDY
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 1:393 ELM GROVE RD
Mailing Address - Street 2:
Mailing Address - City:ALMO
Mailing Address - State:KY
Mailing Address - Zip Code:42020-9147
Mailing Address - Country:US
Mailing Address - Phone:270-703-4136
Mailing Address - Fax:
Practice Address - Street 1:808 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1666
Practice Address - Country:US
Practice Address - Phone:270-759-1288
Practice Address - Fax:270-759-1310
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0160351835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist