Provider Demographics
NPI:1053028027
Name:PENDER, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PENDER
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 1:1117 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-2323
Mailing Address - Country:US
Mailing Address - Phone:636-464-1100
Mailing Address - Fax:
Practice Address - Street 1:1117 MAIN ST
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-2323
Practice Address - Country:US
Practice Address - Phone:636-464-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183700000X
MO15203172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No183700000XPharmacy Service ProvidersPharmacy Technician