Provider Demographics
NPI:1285243220
Name:KONKOL, JONATHAN MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:KONKOL
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 1:9005 LAKE EMILY RD
Mailing Address - Street 2:
Mailing Address - City:AMHERST JUNCTION
Mailing Address - State:WI
Mailing Address - Zip Code:54407-9568
Mailing Address - Country:US
Mailing Address - Phone:608-234-7999
Mailing Address - Fax:
Practice Address - Street 1:511 W CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1462
Practice Address - Country:US
Practice Address - Phone:920-734-3882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI203693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy