Provider Demographics
NPI:1124110960
Name:VOLLERTSEN, KURT WILLIAM
Entity type:Individual
Prefix:MR
First Name:KURT
Middle Name:WILLIAM
Last Name:VOLLERTSEN
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 1:142 S PENN AVE
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:KS
Mailing Address - Zip Code:67749-2243
Mailing Address - Country:US
Mailing Address - Phone:785-475-2285
Mailing Address - Fax:785-470-2470
Practice Address - Street 1:142 S PENN AVE
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:KS
Practice Address - Zip Code:67749-2243
Practice Address - Country:US
Practice Address - Phone:785-475-2285
Practice Address - Fax:785-470-2470
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100440200BMedicaid
KS100440200AMedicaid
KS100440200AMedicaid