Provider Demographics
NPI:1902900277
Name:PIDGEON, KEVIN ANTHONY (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ANTHONY
Last Name:PIDGEON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879
Mailing Address - Country:US
Mailing Address - Phone:951-737-3511
Mailing Address - Fax:951-737-2148
Practice Address - Street 1:800 MAGNOLIA AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3123
Practice Address - Country:US
Practice Address - Phone:951-737-3511
Practice Address - Fax:951-737-2148
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0553506OtherNABP
CAPHA445220Medicaid
CA4546870001Medicare NSC