Provider Demographics
NPI:1205399763
Name:HED, KEVIN LEE
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:HED
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 1:1409 6TH AVE SE STE 2
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4950
Mailing Address - Country:US
Mailing Address - Phone:605-262-0283
Mailing Address - Fax:605-262-0214
Practice Address - Street 1:1409 6TH AVE SE STE 2
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4950
Practice Address - Country:US
Practice Address - Phone:605-262-0283
Practice Address - Fax:605-262-0214
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4923183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4923OtherPHARMACY LICENSE