Healthcare Provider Details

I. General information

NPI: 1750006128
Provider Name (Legal Business Name): KRISTINE JOY MIQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3325 N MAIN ST
ROCKFORD IL
61103-3128
US

IV. Provider business mailing address

3325 N MAIN ST
ROCKFORD IL
61103-3128
US

V. Phone/Fax

Practice location:
  • Phone: 815-877-6084
  • Fax:
Mailing address:
  • Phone: 815-877-6084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051305127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: