Provider Demographics
NPI:1922141035
Name:PENDERGAST, BRIAN MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:PENDERGAST
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 1:2 HEMINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-2224
Mailing Address - Country:US
Mailing Address - Phone:401-431-9020
Mailing Address - Fax:401-434-2026
Practice Address - Street 1:2 HEMINGWAY DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915
Practice Address - Country:US
Practice Address - Phone:401-431-9020
Practice Address - Fax:401-434-2026
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI3619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist