Healthcare Provider Details

I. General information

NPI: 1639080104
Provider Name (Legal Business Name): TATUM BEDORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 E 1ST ST
PRATT KS
67124-2060
US

IV. Provider business mailing address

17008 W LAWSON ST
GODDARD KS
67052-2209
US

V. Phone/Fax

Practice location:
  • Phone: 620-672-5597
  • Fax:
Mailing address:
  • Phone: 785-303-0649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1-110586
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: