Provider Demographics
NPI:1578175394
Name:PEDIGO, TRENT M
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:M
Last Name:PEDIGO
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 1:1057 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-3973
Mailing Address - Country:US
Mailing Address - Phone:309-341-2446
Mailing Address - Fax:
Practice Address - Street 1:1057 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-3973
Practice Address - Country:US
Practice Address - Phone:309-341-2446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.297677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist