Healthcare Provider Details

I. General information

NPI: 1740884683
Provider Name (Legal Business Name): CHARLES ANTHONY MIKULKA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2020
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 W MAIN ST
MOUNT JOY PA
17552-1228
US

IV. Provider business mailing address

441 W MAIN ST
MOUNT JOY PA
17552-1228
US

V. Phone/Fax

Practice location:
  • Phone: 717-653-5298
  • Fax: 717-653-2849
Mailing address:
  • Phone: 717-653-5298
  • Fax: 717-653-2849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP040215L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: