Provider Demographics
NPI:1972938991
Name:KENTOSKI, MICHAEL THOMAS (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:KENTOSKI
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 1:294 COVENTRY ST APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-1973
Mailing Address - Country:US
Mailing Address - Phone:802-487-9048
Mailing Address - Fax:
Practice Address - Street 1:4408 U.S. ROUTE 5
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:VT
Practice Address - Zip Code:05829
Practice Address - Country:US
Practice Address - Phone:802-334-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0096331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist