Healthcare Provider Details

I. General information

NPI: 1780756569
Provider Name (Legal Business Name): STAN BUCZKO RPH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 N MAIN ST
CANTON IL
61520-1828
US

IV. Provider business mailing address

490 N MAIN ST
CANTON IL
61520-1828
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-1717
  • Fax: 309-647-1734
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name: STAN BUCZKO
Title or Position: OWNER PHARMACIST
Credential: RPH
Phone: 309-647-1717