Provider Demographics
NPI:1942761309
Name:KINGDOM HEALTH PLLC
Entity type:Organization
Organization Name:KINGDOM HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:270-967-1616
Mailing Address - Street 1:789 CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:KY
Mailing Address - Zip Code:42064-1858
Mailing Address - Country:US
Mailing Address - Phone:270-967-1616
Mailing Address - Fax:270-967-1617
Practice Address - Street 1:789 CHAPEL HILL RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1858
Practice Address - Country:US
Practice Address - Phone:270-967-1616
Practice Address - Fax:270-967-1617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP08044OtherKY BOARD OF PHARMACY