Provider Demographics
NPI:1093007601
Name:PULTORAK, KEVIN PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PAUL
Last Name:PULTORAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6610 OLD MONROE RD
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-5351
Mailing Address - Country:US
Mailing Address - Phone:704-289-1193
Mailing Address - Fax:704-289-1662
Practice Address - Street 1:6610 OLD MONROE RD
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5351
Practice Address - Country:US
Practice Address - Phone:704-289-1193
Practice Address - Fax:704-289-1662
Is Sole Proprietor?:No
Enumeration Date:2011-05-15
Last Update Date:2011-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0905555Medicaid