Provider Demographics
NPI:1336426329
Name:MCCULLOUGH, KEVIN J (RPH)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:J
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:555 S SUNRISE WAY
Mailing Address - Street 2:SUITE 112-113
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-7869
Mailing Address - Country:US
Mailing Address - Phone:760-323-1973
Mailing Address - Fax:760-320-5236
Practice Address - Street 1:555 S SUNRISE WAY
Practice Address - Street 2:SUITE 112-113
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-7869
Practice Address - Country:US
Practice Address - Phone:760-323-1973
Practice Address - Fax:760-320-5236
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA545491835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689826042Medicaid