Provider Demographics
NPI:1740555960
Name:KOSSAKOWSKI, TERESA D (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:D
Last Name:KOSSAKOWSKI
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 S EMERY AVE
Mailing Address - Street 2:
Mailing Address - City:PESHTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54157-1526
Mailing Address - Country:US
Mailing Address - Phone:608-780-9515
Mailing Address - Fax:
Practice Address - Street 1:2360 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-4065
Practice Address - Country:US
Practice Address - Phone:507-282-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13338-40183500000X
IA20307183500000X
MN116066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist