Healthcare Provider Details

I. General information

NPI: 1205871837
Provider Name (Legal Business Name): KENNETH KUTCH R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 PRUDENTIAL DR
JACKSONVILLE FL
32207-8334
US

IV. Provider business mailing address

11212 TURNBRIDGE DR
JACKSONVILLE FL
32256-2342
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-5261
  • Fax: 904-202-5273
Mailing address:
  • Phone: 904-997-6875
  • Fax: 904-202-5273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS37131
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: