Healthcare Provider Details

I. General information

NPI: 1922927334
Provider Name (Legal Business Name): DEQUAN M GADDIS JR. CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2026
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 30TH AVE
KENOSHA WI
53144-1437
US

IV. Provider business mailing address

1810 30TH AVE
KENOSHA WI
53144-1437
US

V. Phone/Fax

Practice location:
  • Phone: 262-551-8812
  • Fax:
Mailing address:
  • Phone: 262-551-8812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number234598-41
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: