Healthcare Provider Details

I. General information

NPI: 1205358918
Provider Name (Legal Business Name): JOHN D. KUTZKO PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SELAH MOUNTAIN PHARMACY 426 PAGOSA STREET
PAGOSA SPRINGS CO
81147
US

IV. Provider business mailing address

PO BOX 623
PAGOSA SPRINGS CO
81147-0623
US

V. Phone/Fax

Practice location:
  • Phone: 970-264-0126
  • Fax: 970-507-6111
Mailing address:
  • Phone: 941-321-8067
  • Fax: 970-507-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHA.0019440
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: