Provider Demographics
NPI:1174261754
Name:CZECH, JONATHAN MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:CZECH
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 1:6621 44TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55428-5215
Mailing Address - Country:US
Mailing Address - Phone:763-567-3129
Mailing Address - Fax:
Practice Address - Street 1:2024 85TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-1495
Practice Address - Country:US
Practice Address - Phone:763-424-9243
Practice Address - Fax:763-424-9468
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist