Basic Information
Provider Information | |||||||||
NPI: | 1700896362 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KENNEL | ||||||||
FirstName: | SANDRA | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RPH PHARMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MROCHEK | ||||||||
OtherFirstName: | SANDRA | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RPH,PHARMD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4437 S TRACE BLVD | ||||||||
Address2: |   | ||||||||
City: | OLD HICKORY | ||||||||
State: | TN | ||||||||
PostalCode: | 371384206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6158474213 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1310 24TH AVE S | ||||||||
Address2: |   | ||||||||
City: | NASHVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 372122637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6153274751 | ||||||||
FaxNumber: | 6153216310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2006 | ||||||||
LastUpdateDate: | 12/07/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835N1003X | 7691 | TN | Y |   | Pharmacy Service Providers | Pharmacist | Nutrition Support | 183500000X | 7691 | TN | N |   | Pharmacy Service Providers | Pharmacist |   |
No ID Information.