Provider Demographics
NPI:1578180212
Name:CUSACK, KENDAL D (RPH)
Entity Type:Individual
Prefix:
First Name:KENDAL
Middle Name:D
Last Name:CUSACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:503-988-5423
Mailing Address - Fax:503-988-5750
Practice Address - Street 1:3653 SE 34TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-3034
Practice Address - Country:US
Practice Address - Phone:503-988-5423
Practice Address - Fax:503-988-5750
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7534183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist