Provider Demographics
NPI:1053930420
Name:KETRON, MOLLY MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:MARIE
Last Name:KETRON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 MALVERN CT
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-5084
Mailing Address - Country:US
Mailing Address - Phone:423-306-1407
Mailing Address - Fax:
Practice Address - Street 1:5104 BOBBY HICKS HWY
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-6217
Practice Address - Country:US
Practice Address - Phone:423-477-3372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202217047183500000X
TN42260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist