Provider Demographics
NPI:1336554005
Name:PRUITT, KEVIN V (PHD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:PRUITT
Suffix:V
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 AVENUE R NW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-2147
Mailing Address - Country:US
Mailing Address - Phone:863-229-5978
Mailing Address - Fax:
Practice Address - Street 1:105 AVENUE R NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2147
Practice Address - Country:US
Practice Address - Phone:863-229-5978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-21
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist