Healthcare Provider Details

I. General information

NPI: 1487893160
Provider Name (Legal Business Name): JAMES J CICCHESE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 CHICAGO AVE SUITE 120
MINNEAPOLIS MN
55404-4522
US

IV. Provider business mailing address

2545 CHICAGO AVE SUITE 120
MINNEAPOLIS MN
55404-4522
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-2882
  • Fax: 612-863-5702
Mailing address:
  • Phone: 612-863-2882
  • Fax: 612-863-5702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number115212
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: