Provider Demographics
NPI:1215913405
Name:HENJUM, KEN L (RPH)
Entity type:Individual
Prefix:
First Name:KEN
Middle Name:L
Last Name:HENJUM
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 1:12722 DOVER DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8652
Mailing Address - Country:US
Mailing Address - Phone:952-393-5962
Mailing Address - Fax:651-209-2979
Practice Address - Street 1:1299 PROMENADE PL
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2293
Practice Address - Country:US
Practice Address - Phone:651-209-2974
Practice Address - Fax:651-209-2979
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN110878-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist