Provider Demographics
NPI:1336656479
Name:KOVALICK, MARK JOHN (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:KOVALICK
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 1:46 COLONY DR
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18202-9540
Mailing Address - Country:US
Mailing Address - Phone:570-579-4846
Mailing Address - Fax:
Practice Address - Street 1:14 5TH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-6201
Practice Address - Country:US
Practice Address - Phone:570-321-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039533L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist