Provider Demographics
NPI:1841580867
Name:KENNEDY, LARA RAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:RAE
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22549 W 72ND TER
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66227-2624
Mailing Address - Country:US
Mailing Address - Phone:952-913-6166
Mailing Address - Fax:
Practice Address - Street 1:1664 BEDFORD LN
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-4449
Practice Address - Country:US
Practice Address - Phone:952-913-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5343183500000X
MN118001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist