Provider Demographics
NPI:1104143015
Name:RAVAL, KEVIN CLARK (RPH)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:CLARK
Last Name:RAVAL
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 1:6745 FERRI CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6036
Mailing Address - Country:US
Mailing Address - Phone:386-304-9866
Mailing Address - Fax:
Practice Address - Street 1:1300 W INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1440
Practice Address - Country:US
Practice Address - Phone:386-252-9659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-02
Last Update Date:2010-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist