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General NPI Number Information
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NPI Number | 1902189343
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Entity Type | Individual
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Provider Name | KENNETH RAY PEARSON R.PH.
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Gender | Male
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Dates
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Enumeration Date | 09/22/2011
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Last Update Date | 09/22/2011
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Provider Practice Location Address
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Address Line | 226 N HALLECK ST
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City | DEMOTTE
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State | IN
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Zip | 46310-8633
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Country | US
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Telephone | 219-987-4900
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Fax |
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Provider Business Mailing Address
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Address Line | 11118 WOODSIDE DR
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City | DEMOTTE
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State | IN
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Zip | 46310-7801
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Country | US
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Telephone | 219-987-8120
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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 | 26018653A
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License Number State | IN
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