Healthcare Provider Details

I. General information

NPI: 1093451924
Provider Name (Legal Business Name): KENNY BEDOYA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W HUDSON AVE
ENGLEWOOD NJ
07631-1788
US

IV. Provider business mailing address

46 W HUDSON AVE
ENGLEWOOD NJ
07631-1719
US

V. Phone/Fax

Practice location:
  • Phone: 201-408-1374
  • Fax: 201-408-1381
Mailing address:
  • Phone: 201-556-7581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04239300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: