Healthcare Provider Details

I. General information

NPI: 1801118955
Provider Name (Legal Business Name): BRENDA MARIE PEDERSON RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2010
Last Update Date: 02/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6616 UNION LAKE TRL
LONSDALE MN
55046-4324
US

IV. Provider business mailing address

6616 UNION LAKE TRL
LONSDALE MN
55046-4324
US

V. Phone/Fax

Practice location:
  • Phone: 507-744-2958
  • Fax: 507-744-5894
Mailing address:
  • Phone: 507-744-2958
  • Fax: 507-744-5894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number114314
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: