Provider Demographics
NPI:1346339215
Name:RODENHIZER, BRENT KERRY (R PH)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:KERRY
Last Name:RODENHIZER
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:ND
Mailing Address - Zip Code:58784-0460
Mailing Address - Country:US
Mailing Address - Phone:701-628-2255
Mailing Address - Fax:701-628-2396
Practice Address - Street 1:107 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:ND
Practice Address - Zip Code:58784-0460
Practice Address - Country:US
Practice Address - Phone:701-628-2255
Practice Address - Fax:701-628-2396
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND3905OtherPHARMACIST LICENSE NUMBER
AZ8300OtherPHARMACIST LICENSE NUMBER