Provider Demographics
NPI:1194329367
Name:GANDAHO, KENNETH (PHARM D)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:GANDAHO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 PALACE CT
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-1748
Mailing Address - Country:US
Mailing Address - Phone:314-445-8090
Mailing Address - Fax:
Practice Address - Street 1:3881 MEXICO RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-3042
Practice Address - Country:US
Practice Address - Phone:636-922-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-28
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018037591183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist