Provider Demographics
NPI:1629885538
Name:KONKUS, CHARLES ROBERT (RPH)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:KONKUS
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 1:2689 BECKETT ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-1102
Mailing Address - Country:US
Mailing Address - Phone:513-335-8696
Mailing Address - Fax:513-409-5653
Practice Address - Street 1:4865 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-1932
Practice Address - Country:US
Practice Address - Phone:513-335-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH18493183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist