Provider Demographics
NPI:1487991378
Name:KAISER, KEVIN M
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:KAISER
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 1:1223 HARDY POINTE DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5294
Mailing Address - Country:US
Mailing Address - Phone:706-860-8785
Mailing Address - Fax:
Practice Address - Street 1:5119 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-6445
Practice Address - Country:US
Practice Address - Phone:706-650-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist