Provider Demographics
NPI:1124461777
Name:HALLIWELL, TEDENE (RPH)
Entity type:Individual
Prefix:
First Name:TEDENE
Middle Name:
Last Name:HALLIWELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:FAIRWAY
Mailing Address - State:KS
Mailing Address - Zip Code:66205-1705
Mailing Address - Country:US
Mailing Address - Phone:913-236-4983
Mailing Address - Fax:
Practice Address - Street 1:2724 W 53RD ST
Practice Address - Street 2:
Practice Address - City:FAIRWAY
Practice Address - State:KS
Practice Address - Zip Code:66205-1705
Practice Address - Country:US
Practice Address - Phone:913-236-4983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-14
Last Update Date:2013-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-11759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist