Provider Demographics
NPI:1821169822
Name:KMEZICH, THOMAS (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:KMEZICH
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 1:840 E STANDISH PL
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1871
Mailing Address - Country:US
Mailing Address - Phone:414-228-8042
Mailing Address - Fax:
Practice Address - Street 1:2015 E NEWPORT AVENUE, M121
Practice Address - Street 2:CSM COMMUNITY PHARMACIES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211
Practice Address - Country:US
Practice Address - Phone:414-961-3581
Practice Address - Fax:414-961-5378
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11240-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist