Provider Demographics
NPI:1396716015
Name:MILEFCHIK, MARTY JON (RPH)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:JON
Last Name:MILEFCHIK
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 1:5507 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-5727
Mailing Address - Country:US
Mailing Address - Phone:309-792-1147
Mailing Address - Fax:309-797-1999
Practice Address - Street 1:2014 1ST STREET A
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7728
Practice Address - Country:US
Practice Address - Phone:309-797-9320
Practice Address - Fax:309-797-1999
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-040865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist