Healthcare Provider Details

I. General information

NPI: 1285243220
Provider Name (Legal Business Name): JONATHAN MICHAEL KONKOL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W CALUMET ST
APPLETON WI
54915-1462
US

IV. Provider business mailing address

9005 LAKE EMILY RD
AMHERST JUNCTION WI
54407-9568
US

V. Phone/Fax

Practice location:
  • Phone: 920-734-3882
  • Fax:
Mailing address:
  • Phone: 608-234-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20369
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: