Provider Demographics
NPI:1447478151
Name:DIRK, KENNETH (PHARMD,MBA)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:DIRK
Suffix:
Gender:M
Credentials:PHARMD,MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4636 E NARCISSUS CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7002
Mailing Address - Country:US
Mailing Address - Phone:208-433-8721
Mailing Address - Fax:
Practice Address - Street 1:1219 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3701
Practice Address - Country:US
Practice Address - Phone:208-433-9905
Practice Address - Fax:208-433-9907
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5175183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist