MEDICARE: STAN BUCZKO RPH

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	3336C0003X	Community/Retail Pharmacy
2	333600000X	Pharmacy		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1448857	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1780756569
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STAN BUCZKO RPH

Provider Business Mailing Address
First Line	:	490 N MAIN ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-1828
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	490 N MAIN ST
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-1828
Country	:	US
Telephone Number	:	309-647-1717
Fax Number	:	309-647-1734

Authorized Official
Title or Position	:	OWNER PHARMACIST
Name	:	STAN BUCZKO
Credential	:	RPH
Telephone Number	:	309-647-1717

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	03/07/2023

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