Healthcare Provider Details

I. General information

NPI: 1336369115
Provider Name (Legal Business Name): JOEL LEE KACZINSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 05/23/2026
Certification Date: 05/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W327S8163 MEMORY LN
MUKWONAGO WI
53149-8606
US

IV. Provider business mailing address

W327S8163 MEMORY LN
MUKWONAGO WI
53149-8606
US

V. Phone/Fax

Practice location:
  • Phone: 262-363-3939
  • Fax:
Mailing address:
  • Phone: 262-363-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number12879-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: