Healthcare Provider Details

I. General information

NPI: 1891062543
Provider Name (Legal Business Name): MR. JONATHAN RICHARD KUCKHAHN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 W COUNTY ROAD 42
SAVAGE MN
55378-2193
US

IV. Provider business mailing address

8100 W COUNTY ROAD 42
SAVAGE MN
55378-2193
US

V. Phone/Fax

Practice location:
  • Phone: 952-226-1283
  • Fax:
Mailing address:
  • Phone: 952-226-1283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number116006-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: