Healthcare Provider Details

I. General information

NPI: 1891086153
Provider Name (Legal Business Name): THOMAS CHARLES KUKLINSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 LIBERTY ST
ERIE PA
16502-1650
US

IV. Provider business mailing address

1709 LIBERTY ST
ERIE PA
16502-1650
US

V. Phone/Fax

Practice location:
  • Phone: 814-452-2596
  • Fax:
Mailing address:
  • Phone: 814-452-2596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP027408L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: