Provider Demographics
NPI:1043948110
Name:SMITH, KENNETH JOHN
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:SMITH
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 1:27380 COOK RD APT 27
Mailing Address - Street 2:
Mailing Address - City:OLMSTED TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44138-1095
Mailing Address - Country:US
Mailing Address - Phone:440-724-8198
Mailing Address - Fax:
Practice Address - Street 1:11702 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5442
Practice Address - Country:US
Practice Address - Phone:216-671-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03215433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist