Provider Demographics
NPI:1801159397
Name:WURTZ, KEVIN GLENN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GLENN
Last Name:WURTZ
Suffix:
Gender:M
Credentials:PHARMACIST
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 489
Mailing Address - Street 2:
Mailing Address - City:ELK POINT
Mailing Address - State:SD
Mailing Address - Zip Code:57025-0489
Mailing Address - Country:US
Mailing Address - Phone:605-356-3336
Mailing Address - Fax:
Practice Address - Street 1:107 E MAIN
Practice Address - Street 2:
Practice Address - City:ELK POINT
Practice Address - State:SD
Practice Address - Zip Code:57025-0489
Practice Address - Country:US
Practice Address - Phone:605-356-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3912183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0790030001Medicare NSC