Provider Demographics
NPI:1811109036
Name:LUTOVSKY, KIMBALL ANTHONY (RPH)
Entity type:Individual
Prefix:MR
First Name:KIMBALL
Middle Name:ANTHONY
Last Name:LUTOVSKY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 GRIGGS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-1441
Mailing Address - Country:US
Mailing Address - Phone:701-352-3555
Mailing Address - Fax:
Practice Address - Street 1:701 W 6TH ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237-1379
Practice Address - Country:US
Practice Address - Phone:701-352-4216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist