Provider Demographics
NPI:1629382593
Name:MCDERMOTT, KEVIN PAUL (PHARMD, PHC, BCPS)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PAUL
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:PHARMD, PHC, BCPS
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 160
Mailing Address - Street 2:PHARMACY DEPARTMENT
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-7266
Mailing Address - Fax:505-368-7262
Practice Address - Street 1:U.S. HIGHWAY 491 NORTH
Practice Address - Street 2:PHARMACY DEPARTMENT
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-0160
Practice Address - Country:US
Practice Address - Phone:505-368-7266
Practice Address - Fax:505-368-7262
Is Sole Proprietor?:No
Enumeration Date:2010-08-03
Last Update Date:2013-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00070717183500000X, 1835P0018X
WAPH 000707171835P1200X
NMRP00007971183500000X
NMPC000002171835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy