1912182056 NPI number — MS. JACQUELINE ALICE KONKOL R.PH

Table of content: MS. JACQUELINE ALICE KONKOL R.PH (NPI 1912182056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912182056 NPI number — MS. JACQUELINE ALICE KONKOL R.PH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONKOL
Provider First Name:
JACQUELINE
Provider Middle Name:
ALICE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.PH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATIKIEWICZ
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
ALICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912182056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
657 BROADWAY
Provider Second Line Business Mailing Address:
RITE AID #1302
Provider Business Mailing Address City Name:
NEWBURGH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-561-1090
Provider Business Mailing Address Fax Number:
845-863-0244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
657 BROADWAY
Provider Second Line Business Practice Location Address:
RITE AID #1302
Provider Business Practice Location Address City Name:
NEWBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-561-1090
Provider Business Practice Location Address Fax Number:
845-863-0244
Provider Enumeration Date:
01/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  041343 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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