Provider Demographics
NPI:1093386906
Name:PELTER, KEVIN (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PELTER
Suffix:
Gender:M
Credentials:PHARMD, RPH
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 107
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:OH
Mailing Address - Zip Code:44882-0107
Mailing Address - Country:US
Mailing Address - Phone:419-927-2691
Mailing Address - Fax:
Practice Address - Street 1:119 S SYCAMORE AVENUE
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:OH
Practice Address - Zip Code:44882
Practice Address - Country:US
Practice Address - Phone:419-927-2691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03131801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist