Healthcare Provider Details

I. General information

NPI: 1265453757
Provider Name (Legal Business Name): KENDALL R PETERSON R. PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 COUNTY ROAD 42 E
BURNSVILLE MN
55306-5706
US

IV. Provider business mailing address

532 EASTWOOD CT
EAGAN MN
55123-3067
US

V. Phone/Fax

Practice location:
  • Phone: 952-435-8145
  • Fax: 952-435-5513
Mailing address:
  • Phone: 651-688-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number116694-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: