Healthcare Provider Details

I. General information

NPI: 1215212204
Provider Name (Legal Business Name): JACUB MICHAEL KALISZEWSKI PHARMD, RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 GRAND AVE
DULUTH MN
55807-2754
US

IV. Provider business mailing address

4501 GRAND AVE
DULUTH MN
55807-2754
US

V. Phone/Fax

Practice location:
  • Phone: 218-628-2897
  • Fax: 218-624-5853
Mailing address:
  • Phone: 218-628-2897
  • Fax: 218-624-5853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number120242
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16057-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: