Healthcare Provider Details

I. General information

NPI: 1831727395
Provider Name (Legal Business Name): MARK THOMAS KENNEDY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 S LAKESHORE DR
LAKE CITY MN
55041-1642
US

IV. Provider business mailing address

223 S LAKESHORE DR
LAKE CITY MN
55041-1642
US

V. Phone/Fax

Practice location:
  • Phone: 651-345-3411
  • Fax: 651-345-4848
Mailing address:
  • Phone: 651-345-3411
  • Fax: 651-345-4848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number113768
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: