Provider Demographics
NPI:1134716731
Name:KRUEGER, KENNETH ROBERT (RPH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:KRUEGER
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 1:325 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:61238-1122
Mailing Address - Country:US
Mailing Address - Phone:309-937-2725
Mailing Address - Fax:
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-2818
Practice Address - Country:US
Practice Address - Phone:309-853-4412
Practice Address - Fax:309-853-9810
Is Sole Proprietor?:No
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051034094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist