Provider Demographics
NPI:1720411929
Name:PHILLIPS, KEVIN (RPH)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2027
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-2027
Mailing Address - Country:US
Mailing Address - Phone:252-473-5801
Mailing Address - Fax:252-473-2130
Practice Address - Street 1:210 SOUTH HWY 64/264
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954-2027
Practice Address - Country:US
Practice Address - Phone:252-473-5801
Practice Address - Fax:252-473-2130
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13892183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1034450001Medicare NSC