Provider Demographics
NPI:1366573297
Name:MALKEN PHARM SERVICES INC
Entity type:Organization
Organization Name:MALKEN PHARM SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BRANT
Authorized Official - Last Name:KICKLIGHTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:912-653-2772
Mailing Address - Street 1:P.O BOX 1329
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321
Mailing Address - Country:US
Mailing Address - Phone:912-653-2772
Mailing Address - Fax:912-653-2752
Practice Address - Street 1:137 E. BACON ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:GA
Practice Address - Zip Code:31321
Practice Address - Country:US
Practice Address - Phone:912-653-2772
Practice Address - Fax:912-653-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
GAPHRE0058543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2013956OtherPK
GA00143822AMedicaid