Provider Demographics
NPI:1013538818
Name:BUCKLEY, KENNETH PATRICK (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PATRICK
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5227
Mailing Address - Country:US
Mailing Address - Phone:507-625-1791
Mailing Address - Fax:507-625-9262
Practice Address - Street 1:1175 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5227
Practice Address - Country:US
Practice Address - Phone:507-625-1791
Practice Address - Fax:507-625-9262
Is Sole Proprietor?:No
Enumeration Date:2020-05-03
Last Update Date:2020-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120201183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN120201OtherPHARMACIST LICENSE