Provider Demographics
NPI:1992146906
Name:KOSTLEVY, EDWARD LEE (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:LEE
Last Name:KOSTLEVY
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 1:1008 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-2121
Mailing Address - Country:US
Mailing Address - Phone:715-743-6632
Mailing Address - Fax:715-743-6679
Practice Address - Street 1:1008 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-2121
Practice Address - Country:US
Practice Address - Phone:715-743-6632
Practice Address - Fax:715-743-6679
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8497-00183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist