Healthcare Provider Details

I. General information

NPI: 1184117616
Provider Name (Legal Business Name): STEPHEN MIECZKOWSKI RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2018
Last Update Date: 06/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4531 MAIN ST
BRIDGEPORT CT
06606-1846
US

IV. Provider business mailing address

546 WILCOXSON AVE
STRATFORD CT
06614-4237
US

V. Phone/Fax

Practice location:
  • Phone: 203-371-6972
  • Fax:
Mailing address:
  • Phone: 203-218-8526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPCT.0004802
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: