Provider Demographics
NPI:1336369115
Name:KACZINSKI, JOEL LEE
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:LEE
Last Name:KACZINSKI
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:W327S8163 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-8606
Mailing Address - Country:US
Mailing Address - Phone:262-363-3939
Mailing Address - Fax:
Practice Address - Street 1:W327S8163 MEMORY LN
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8606
Practice Address - Country:US
Practice Address - Phone:262-363-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12879-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist