Provider Demographics
NPI:1265211858
Name:BRUTAS, JOHN KENNETH
Entity type:Individual
Prefix:
First Name:JOHN KENNETH
Middle Name:
Last Name:BRUTAS
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 1:1617 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-1877
Mailing Address - Country:US
Mailing Address - Phone:215-840-4893
Mailing Address - Fax:
Practice Address - Street 1:835 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-1601
Practice Address - Country:US
Practice Address - Phone:215-886-2923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP457944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist