Provider Demographics
NPI:1427830553
Name:KMIECIAK, JOHN JOSEPH JR (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:KMIECIAK
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5729 JACKIES DR
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-3436
Mailing Address - Country:US
Mailing Address - Phone:779-221-1149
Mailing Address - Fax:
Practice Address - Street 1:1145 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3613
Practice Address - Country:US
Practice Address - Phone:815-398-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.305906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist