Provider Demographics
NPI:1780091843
Name:PEDERSON, BRIAN (RPH)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:PEDERSON
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 1:12430 W EBERLY CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-9649
Mailing Address - Country:US
Mailing Address - Phone:913-669-9125
Mailing Address - Fax:
Practice Address - Street 1:12430 W EBERLY CT
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67235-9649
Practice Address - Country:US
Practice Address - Phone:913-669-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-13187183500000X
TX36320183500000X
MO20030018137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist