Provider Demographics
NPI:1487059556
Name:KENNY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KENNY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#6 TOWN PLAZA SHOP CENTER
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301
Mailing Address - Country:US
Mailing Address - Phone:970-247-4485
Mailing Address - Fax:
Practice Address - Street 1:3130 MAIN AVE
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-4247
Practice Address - Country:US
Practice Address - Phone:970-247-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020354183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist