Provider Demographics
NPI:1760099683
Name:BOKOWY, MITCHELL WALTER
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:WALTER
Last Name:BOKOWY
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 1:2323 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-1550
Mailing Address - Country:US
Mailing Address - Phone:815-399-1474
Mailing Address - Fax:
Practice Address - Street 1:2323 CHARLES ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1550
Practice Address - Country:US
Practice Address - Phone:815-399-1474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051303060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051303060OtherALL INSURANCES