Provider Demographics
NPI:1871587824
Name:BRYAN, KENNETH RODOLFO (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RODOLFO
Last Name:BRYAN
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 1:1304 PATRICIA DR
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-4760
Mailing Address - Country:US
Mailing Address - Phone:402-592-5784
Mailing Address - Fax:
Practice Address - Street 1:2501 CAPEHART RD
Practice Address - Street 2:
Practice Address - City:OFFUTT A F B
Practice Address - State:NE
Practice Address - Zip Code:68113-1043
Practice Address - Country:US
Practice Address - Phone:402-294-3228
Practice Address - Fax:402-294-0711
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021404A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist