Provider Demographics
NPI:1497008239
Name:SIMON, KENNETH D
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:SIMON
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 1:1325 MISSISSIPPI DR
Mailing Address - Street 2:
Mailing Address - City:DAKOTA
Mailing Address - State:MN
Mailing Address - Zip Code:55925-7171
Mailing Address - Country:US
Mailing Address - Phone:507-643-6677
Mailing Address - Fax:
Practice Address - Street 1:2511 GREEN BAY ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5900
Practice Address - Country:US
Practice Address - Phone:608-775-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN114107183500000X
WI9813-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist