Provider Demographics
NPI:1043505506
Name:KOENECKE, STEVEN GEORGE (RPH)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:GEORGE
Last Name:KOENECKE
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 1:5071 KIPLING ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-2251
Mailing Address - Country:US
Mailing Address - Phone:303-209-1849
Mailing Address - Fax:303-209-1849
Practice Address - Street 1:5071 KIPLING ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-2251
Practice Address - Country:US
Practice Address - Phone:303-209-1849
Practice Address - Fax:303-209-1849
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10144OtherPHARMACY LICENSE NUMBER