MEDICARE: MR. KENDAL L PEDERSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	11268	NV
2	183500000X	Pharmacist	9065	OR

General Provider Information

NPI Number	:	1790012680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENDAL L PEDERSEN

Provider Business Mailing Address
First Line	:	5500 BOULDER HWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6010
Country	:	US
Telephone Number	:	702-435-7339
Fax Number	:	702-352-1082

Provider Business Practice Location Address
First Line	:	5500 BOULDER HWY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122-6010
Country	:	US
Telephone Number	:	702-435-7339
Fax Number	:	702-352-1082

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2009
Last Update Date	:	11/12/2009

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Directions to “ MR. KENDAL L PEDERSEN ” Practice Location

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