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General NPI Number Information
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NPI Number | 1497008239
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Entity Type | Individual
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Provider Name | MR. KENNETH D SIMON
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Gender | Male
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Dates
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Enumeration Date | 10/17/2012
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Last Update Date | 10/17/2012
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Provider Practice Location Address
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Address Line | 2511 GREEN BAY ST
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City | LA CROSSE
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State | WI
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Zip | 54601-5900
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Country | US
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Telephone | 608-775-8585
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Fax |
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Provider Business Mailing Address
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Address Line | 1325 MISSISSIPPI DR
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City | DAKOTA
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State | MN
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Zip | 55925-7171
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Country | US
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Telephone | 507-643-6677
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 114107
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 9813-40
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License Number State | WI
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