Healthcare Provider Details

I. General information

NPI: 1194350595
Provider Name (Legal Business Name): AMY KUKACKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 COMMERCE DR
WOODBURY MN
55125-4872
US

IV. Provider business mailing address

449 COMMERCE DR
WOODBURY MN
55125-4872
US

V. Phone/Fax

Practice location:
  • Phone: 651-239-1875
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1549772
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: