Healthcare Provider Details

I. General information

NPI: 1104107390
Provider Name (Legal Business Name): JOHN E KOCKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 12/17/2022
Certification Date: 12/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12098 LUSHER RD
SAINT LOUIS MO
63138-1302
US

IV. Provider business mailing address

2532 N ILLINOIS ST
SWANSEA IL
62226-2353
US

V. Phone/Fax

Practice location:
  • Phone: 314-355-0500
  • Fax: 314-355-9695
Mailing address:
  • Phone: 618-236-3928
  • Fax: 618-236-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.293992
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2001024845
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: