Provider Demographics
NPI:1992939920
Name:KONICKI, PETER X (RPH)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:X
Last Name:KONICKI
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 1:278 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:PA
Mailing Address - Zip Code:18641-0000
Mailing Address - Country:US
Mailing Address - Phone:570-655-8610
Mailing Address - Fax:570-883-0488
Practice Address - Street 1:278 MAIN ST
Practice Address - Street 2:
Practice Address - City:DUPONT
Practice Address - State:PA
Practice Address - Zip Code:18641-1960
Practice Address - Country:US
Practice Address - Phone:570-655-8610
Practice Address - Fax:570-883-0488
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410933L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100744051002Medicaid
3962331OtherNABP/NCPDP
3962331OtherNABP/NCPDP