MEDICARE: JOHN KRAKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	036121	NY

General Provider Information

NPI Number	:	1336461474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN KRAKE

Provider Business Mailing Address
First Line	:	1729 STATE ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-3101
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1729 STATE ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-3101
Country	:	US
Telephone Number	:	315-788-3570
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2010
Last Update Date	:	02/16/2010

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