Provider Demographics
NPI:1992391304
Name:KRUPCZAK, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KRUPCZAK
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 1:194 BEEKMAN DR
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-2605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1277 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-1165
Practice Address - Country:US
Practice Address - Phone:413-732-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH239741183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist