Provider Demographics
NPI:1952686107
Name:FERGUSON, IVAN E JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:E
Last Name:FERGUSON
Suffix:JR
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 1:4630 TROOST AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64110-1712
Mailing Address - Country:US
Mailing Address - Phone:816-931-8337
Mailing Address - Fax:816-931-4980
Practice Address - Street 1:2630 NE VIVION ROAD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64119-2513
Practice Address - Country:US
Practice Address - Phone:816-459-7175
Practice Address - Fax:816-459-7686
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042199183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1982619904Medicaid