Provider Demographics
NPI:1689280125
Name:PEDERSEN, PERRY (RPH)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:
Last Name:PEDERSEN
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 1:13251 CHACO CANYON LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7117
Mailing Address - Country:US
Mailing Address - Phone:505-821-5165
Mailing Address - Fax:
Practice Address - Street 1:13251 CHACO CANYON LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-7117
Practice Address - Country:US
Practice Address - Phone:505-821-5165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010684183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist