Provider Demographics
NPI:1104426568
Name:PUTOREK, JOHN LOUIS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOUIS
Last Name:PUTOREK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 BLUERIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-4226
Mailing Address - Country:US
Mailing Address - Phone:304-431-2105
Mailing Address - Fax:304-431-2116
Practice Address - Street 1:176 BLUERIDGE AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-4226
Practice Address - Country:US
Practice Address - Phone:304-431-2105
Practice Address - Fax:304-431-2116
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV5094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist