Provider Demographics
NPI:1174685663
Name:TYCZKOWSKI, PETER (RPH)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:TYCZKOWSKI
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 1:523 E CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-3302
Mailing Address - Country:US
Mailing Address - Phone:860-486-3151
Mailing Address - Fax:
Practice Address - Street 1:69 N EAGLEVILLE RD UNIT 3092
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06269-3092
Practice Address - Country:US
Practice Address - Phone:860-486-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5409183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist