Provider Demographics
NPI:1144532334
Name:PEDEN, KIM
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:PEDEN
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 1:14025 NACOGDOCHES RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-1918
Mailing Address - Country:US
Mailing Address - Phone:210-656-5041
Mailing Address - Fax:210-656-0239
Practice Address - Street 1:14025 NACOGDOCHES RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-1918
Practice Address - Country:US
Practice Address - Phone:210-656-5041
Practice Address - Fax:210-656-0239
Is Sole Proprietor?:No
Enumeration Date:2010-07-05
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist