Provider Demographics
NPI:1588300651
Name:PUCIK, KENDAL M
Entity type:Individual
Prefix:
First Name:KENDAL
Middle Name:M
Last Name:PUCIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 SW SUMMERTON ST
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-6851
Mailing Address - Country:US
Mailing Address - Phone:503-853-1840
Mailing Address - Fax:
Practice Address - Street 1:203 PHARMACY BLDG
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8537
Practice Address - Country:US
Practice Address - Phone:541-737-3424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program