Provider Demographics
NPI:1447943568
Name:WILLOUGHBY, KENNETH WAYNE
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:WILLOUGHBY
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 1:148 NORTHSHORE WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7177
Mailing Address - Country:US
Mailing Address - Phone:601-260-4249
Mailing Address - Fax:
Practice Address - Street 1:2195 HIGHWAY 49 S
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073-9420
Practice Address - Country:US
Practice Address - Phone:601-260-4249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE08123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist