Provider Demographics
NPI:1376146092
Name:PHELPS, KEVIN EDWARD (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:EDWARD
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 LOXLEY RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702-1809
Mailing Address - Country:US
Mailing Address - Phone:757-675-9405
Mailing Address - Fax:
Practice Address - Street 1:2775 GODWIN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8037
Practice Address - Country:US
Practice Address - Phone:757-539-0069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty