Provider Demographics
NPI:1558582916
Name:MACINTOSH, KEVIN IAN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:IAN
Last Name:MACINTOSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 COLONY TRL
Mailing Address - Street 2:
Mailing Address - City:LANEXA
Mailing Address - State:VA
Mailing Address - Zip Code:23089-6004
Mailing Address - Country:US
Mailing Address - Phone:757-764-6497
Mailing Address - Fax:
Practice Address - Street 1:7 NEALY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23665-2023
Practice Address - Country:US
Practice Address - Phone:757-764-6497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist