Provider Demographics
NPI:1619045036
Name:LUCKOVICH, JOHN MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:LUCKOVICH
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 1:150 ELM ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-2504
Mailing Address - Country:US
Mailing Address - Phone:814-355-1741
Mailing Address - Fax:
Practice Address - Street 1:105 N ALLEGHENY ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTE
Practice Address - State:PA
Practice Address - Zip Code:16823-1626
Practice Address - Country:US
Practice Address - Phone:814-355-3225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP022818L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP028102LOtherPHARMACIST