Provider Demographics
NPI:1306911599
Name:KEVIN GLENN WURTZ
Entity type:Organization
Organization Name:KEVIN GLENN WURTZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:605-356-3336
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:ELK POINT
Mailing Address - State:SD
Mailing Address - Zip Code:57025-0489
Mailing Address - Country:US
Mailing Address - Phone:605-356-3336
Mailing Address - Fax:605-356-3202
Practice Address - Street 1:107 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELK POINT
Practice Address - State:SD
Practice Address - Zip Code:57025
Practice Address - Country:US
Practice Address - Phone:605-356-3336
Practice Address - Fax:605-356-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SD100-05103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD8500840Medicaid
4301191OtherNCPDP PROVIDER IDENTIFICATION NUMBER
SD8500840Medicaid