Provider Demographics
NPI:1902230600
Name:KNUTSON, KENNETH M
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:KNUTSON
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 1:1300 HOSPITAL LOOP DR
Mailing Address - Street 2:
Mailing Address - City:BELCOURT
Mailing Address - State:ND
Mailing Address - Zip Code:58316
Mailing Address - Country:US
Mailing Address - Phone:701-477-8426
Mailing Address - Fax:701-477-2524
Practice Address - Street 1:1 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:BELCOURT
Practice Address - State:ND
Practice Address - Zip Code:58316
Practice Address - Country:US
Practice Address - Phone:701-477-8426
Practice Address - Fax:701-477-2524
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.296774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist