Provider Demographics
NPI:1790012680
Name:PEDERSEN, KENDAL L
Entity Type:Individual
Prefix:MR
First Name:KENDAL
Middle Name:L
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 1:5500 BOULDER HWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-6010
Mailing Address - Country:US
Mailing Address - Phone:702-435-7339
Mailing Address - Fax:702-352-1082
Practice Address - Street 1:5500 BOULDER HWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-6010
Practice Address - Country:US
Practice Address - Phone:702-435-7339
Practice Address - Fax:702-352-1082
Is Sole Proprietor?:No
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11268183500000X
OR9065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist