Provider Demographics
NPI:1306080486
Name:FOSHEIM, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:FOSHEIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26433 454TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:SD
Mailing Address - Zip Code:57035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 W. 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105
Practice Address - Country:US
Practice Address - Phone:605-336-3230
Practice Address - Fax:605-333-5305
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5385183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist