MEDICARE: MR. KEVIN J MCCULLOUGH RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	54549	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336426329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN J MCCULLOUGH RPH

Provider Business Mailing Address
First Line	:	555 S SUNRISE WAY
Second Line	:	SUITE 112-113
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-7869
Country	:	US
Telephone Number	:	760-323-1973
Fax Number	:	760-320-5236

Provider Business Practice Location Address
First Line	:	555 S SUNRISE WAY
Second Line	:	SUITE 112-113
City	:	PALM SPRINGS
State	:	CA
Zip	:	92264-7869
Country	:	US
Telephone Number	:	760-323-1973
Fax Number	:	760-320-5236

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2011
Last Update Date	:	11/04/2011

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