Provider Demographics
NPI:1164704839
Name:KAZMIERCZAK030303, RAYMOND
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:KAZMIERCZAK030303
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 1:2906 BALDWIN DR S
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:IN
Mailing Address - Zip Code:47920-9440
Mailing Address - Country:US
Mailing Address - Phone:765-414-0752
Mailing Address - Fax:
Practice Address - Street 1:107 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4601
Practice Address - Country:US
Practice Address - Phone:765-457-3676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26012925A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist