Healthcare Provider Details

I. General information

NPI: 1093896060
Provider Name (Legal Business Name): SAMUEL I KUTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 BRANCH AVE
TEMPLE HILLS MD
20748-1242
US

IV. Provider business mailing address

808 DARIEN PL
LARGO MD
20774-5733
US

V. Phone/Fax

Practice location:
  • Phone: 301-423-8070
  • Fax: 301-423-7707
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11128
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: