Provider Demographics
NPI:1952619520
Name:KUTHIALA, BENITA
Entity Type:Individual
Prefix:
First Name:BENITA
Middle Name:
Last Name:KUTHIALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TALBOT ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-4638
Mailing Address - Country:US
Mailing Address - Phone:732-991-2207
Mailing Address - Fax:
Practice Address - Street 1:2645 S BROAD ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08610-4011
Practice Address - Country:US
Practice Address - Phone:609-888-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02950000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist