Provider Demographics
NPI:1174899553
Name:KENNON, KENT STEPHEN (RPH)
Entity type:Individual
Prefix:MR
First Name:KENT
Middle Name:STEPHEN
Last Name:KENNON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-0416
Mailing Address - Country:US
Mailing Address - Phone:605-569-1310
Mailing Address - Fax:
Practice Address - Street 1:1606 NORTH AVE
Practice Address - Street 2:SAFEWAY PHARMACY
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783
Practice Address - Country:US
Practice Address - Phone:605-342-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR5365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist