Provider Demographics
NPI:1205358918
Name:KUTZKO, JOHN D (PHARM D)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:KUTZKO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-0623
Mailing Address - Country:US
Mailing Address - Phone:941-321-8067
Mailing Address - Fax:970-507-6111
Practice Address - Street 1:SELAH MOUNTAIN PHARMACY
Practice Address - Street 2:426 PAGOSA STREET
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-0126
Practice Address - Fax:970-507-6111
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0019440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS21744OtherFLORIDA BOARD OF PHARMACY
NMRP00007870OtherNEW MEXICO BOARD OF PHARMACY
TX62239OtherTEXAS BOARD OF PHARMACY
COPHA.0019440OtherCOLORADO BOARD OF PHARMACY