Provider Demographics
NPI:1104107390
Name:KOCKA, JOHN E
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:KOCKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2353
Mailing Address - Country:US
Mailing Address - Phone:618-236-3928
Mailing Address - Fax:618-236-0493
Practice Address - Street 1:12098 LUSHER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1302
Practice Address - Country:US
Practice Address - Phone:314-355-0500
Practice Address - Fax:314-355-9695
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293992183500000X
MO2001024845183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist