Provider Demographics
NPI:1184213605
Name:HENDRICKS, HOLDEN
Entity Type:Individual
Prefix:
First Name:HOLDEN
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 SW CARSON DR
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-7853
Mailing Address - Country:US
Mailing Address - Phone:785-643-6542
Mailing Address - Fax:
Practice Address - Street 1:9430 BLUE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64138-3846
Practice Address - Country:US
Practice Address - Phone:816-822-9121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-100907183500000X
MO2020043221183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist