Provider Demographics
NPI:1679604680
Name:MUSTO, KENNETH JOHN JR (RPH)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JOHN
Last Name:MUSTO
Suffix:JR
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 1
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-0001
Mailing Address - Country:US
Mailing Address - Phone:302-653-1653
Mailing Address - Fax:
Practice Address - Street 1:100 S MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1477
Practice Address - Country:US
Practice Address - Phone:302-653-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0002433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist