Provider Demographics
NPI:1053616128
Name:KUCKES, MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KUCKES
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5012 N RINK RD
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-9579
Mailing Address - Country:US
Mailing Address - Phone:815-238-6861
Mailing Address - Fax:
Practice Address - Street 1:405 W 8TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1063
Practice Address - Country:US
Practice Address - Phone:608-325-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037966183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist