Provider Demographics
NPI:1790817534
Name:KACZKA, GARY KEITH (RPH, CCP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:KEITH
Last Name:KACZKA
Suffix:
Gender:M
Credentials:RPH, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NEPOTE PL
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-3478
Mailing Address - Country:US
Mailing Address - Phone:732-208-0415
Mailing Address - Fax:732-873-0465
Practice Address - Street 1:1 NEPOTE PL
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3478
Practice Address - Country:US
Practice Address - Phone:732-208-0415
Practice Address - Fax:732-873-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01937000183500000X
NJ1835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric