Provider Demographics
NPI:1295067841
Name:LUDVIGSON, KELLEN PARK (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:KELLEN
Middle Name:PARK
Last Name:LUDVIGSON
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHEROKEE
Mailing Address - State:IA
Mailing Address - Zip Code:51012-1825
Mailing Address - Country:US
Mailing Address - Phone:712-225-2320
Mailing Address - Fax:712-225-2319
Practice Address - Street 1:206 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:IA
Practice Address - Zip Code:51012-1825
Practice Address - Country:US
Practice Address - Phone:712-225-2320
Practice Address - Fax:712-225-2319
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20725183500000X
MN118848183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist