Provider Demographics
NPI:1750965638
Name:FUSSELMAN, KEVIN MICHAEL
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:FUSSELMAN
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 1:2147 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44314-2233
Mailing Address - Country:US
Mailing Address - Phone:330-753-5021
Mailing Address - Fax:
Practice Address - Street 1:2147 EAST AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44314-2233
Practice Address - Country:US
Practice Address - Phone:330-753-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03335075183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist