Provider Demographics
NPI:1295288645
Name:VAITUKAITIS, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:VAITUKAITIS
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 1:10620 PINE NEEDLE RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-4838
Mailing Address - Country:US
Mailing Address - Phone:410-982-7300
Mailing Address - Fax:
Practice Address - Street 1:19869 SEA BLOSSOM BLVD
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-7142
Practice Address - Country:US
Practice Address - Phone:302-226-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0004965183500000X
MD24206183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist