Basic Information
| Provider Information | |||||||||
| NPI: | 1720585268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCAMISH | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1014 PEBBLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471305792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129460290 | ||||||||
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| Practice Location | |||||||||
| Address1: | 530 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025623000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 04/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 011411 | KY | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | PH000400009 | WA | N | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P0018X | 26017988A | IN | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
ID Information
| ID | Type | State | Issuer | Description | 011411 | 01 | KY | KENTUCKY BOARD OF PHARMACY | OTHER | 26017988A | 01 | IN | INDIANA BOARD OF PHARMACY | OTHER | PH00040009 | 01 | WA | WASHINGTON STATE BOARD OF PHARMACY | OTHER |