Healthcare Provider Details

I. General information

NPI: 1104426568
Provider Name (Legal Business Name): JOHN LOUIS PUTOREK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 BLUERIDGE AVE
PRINCETON WV
24740-4226
US

IV. Provider business mailing address

176 BLUERIDGE AVE
PRINCETON WV
24740-4226
US

V. Phone/Fax

Practice location:
  • Phone: 304-431-2105
  • Fax: 304-431-2116
Mailing address:
  • Phone: 304-431-2105
  • Fax: 304-431-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5094
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: