Provider Demographics
NPI:1518213701
Name:STUTT, KEVIN M (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:STUTT
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:SUITE 100E
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6531
Mailing Address - Fax:
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:PHARMACY
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16749-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist