Provider Demographics
NPI:1598037392
Name:PEDERSEN, DENNIS LAVERN
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:LAVERN
Last Name:PEDERSEN
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 1:867 N COLUMBIA CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7771
Mailing Address - Country:US
Mailing Address - Phone:509-736-0505
Mailing Address - Fax:
Practice Address - Street 1:867 N COLUMBIA CENTER BLVD
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7771
Practice Address - Country:US
Practice Address - Phone:509-736-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist