Healthcare Provider Details

I. General information

NPI: 1053616128
Provider Name (Legal Business Name): MICHAEL KUCKES RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W 8TH ST
MONROE WI
53566-1063
US

IV. Provider business mailing address

5012 N RINK RD
LENA IL
61048-9579
US

V. Phone/Fax

Practice location:
  • Phone: 608-325-3310
  • Fax:
Mailing address:
  • Phone: 815-238-6861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-037966
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: