Provider Demographics
NPI:1831307412
Name:WONSOWSKI, KEVIN (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:WONSOWSKI
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 1:2705 KOLBY CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1505
Mailing Address - Country:US
Mailing Address - Phone:309-664-2521
Mailing Address - Fax:309-664-3255
Practice Address - Street 1:2705 KOLBY CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-1505
Practice Address - Country:US
Practice Address - Phone:309-664-2521
Practice Address - Fax:309-664-3255
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist