Provider Demographics
NPI:1013983105
Name:BODENHAGEN, KENNETH MARK (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MARK
Last Name:BODENHAGEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13963 S TRAILS END DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8643
Mailing Address - Country:US
Mailing Address - Phone:708-645-1678
Mailing Address - Fax:630-679-6565
Practice Address - Street 1:225 N WEBER RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-1505
Practice Address - Country:US
Practice Address - Phone:630-679-6533
Practice Address - Fax:630-679-6565
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist