Basic Information
| Provider Information | |||||||||
| NPI: | 1922141035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENDERGAST | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 HEMINGWAY DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029152224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014319020 | ||||||||
| FaxNumber: | 4014342026 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 HEMINGWAY DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014319020 | ||||||||
| FaxNumber: | 4014342026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 3619 | RI | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.