Provider Demographics
NPI:1376661892
Name:PEDERSON, PHILIP ANDREW (PHARMD)
Entity type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:ANDREW
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 LYNX LN
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-8653
Mailing Address - Country:US
Mailing Address - Phone:507-381-1317
Mailing Address - Fax:
Practice Address - Street 1:2010 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6817
Practice Address - Country:US
Practice Address - Phone:507-625-7565
Practice Address - Fax:507-625-2606
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist