Provider Demographics
NPI:1376695247
Name:KENNEDY, BRIAN DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DAVID
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30151 715TH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-5002
Mailing Address - Country:US
Mailing Address - Phone:651-345-5010
Mailing Address - Fax:651-345-1158
Practice Address - Street 1:223 S LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1642
Practice Address - Country:US
Practice Address - Phone:651-345-3411
Practice Address - Fax:651-345-4848
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115760-6183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist