Provider Demographics
NPI:1902189343
Name:PEARSON, KENNETH RAY (RPH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAY
Last Name:PEARSON
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 1:11118 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-7801
Mailing Address - Country:US
Mailing Address - Phone:219-987-8120
Mailing Address - Fax:
Practice Address - Street 1:226 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8633
Practice Address - Country:US
Practice Address - Phone:219-987-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018653A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist