Provider Demographics
NPI:1932483534
Name:KUSKA, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KUSKA
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 1:1001 W REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9776
Mailing Address - Country:US
Mailing Address - Phone:815-844-4767
Mailing Address - Fax:815-844-4467
Practice Address - Street 1:1001 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9776
Practice Address - Country:US
Practice Address - Phone:815-844-4767
Practice Address - Fax:815-844-4467
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-01
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist