Provider Demographics
NPI:1003894973
Name:KOHLERS FOOD STORES PHAMACY
Entity Type:Organization
Organization Name:KOHLERS FOOD STORES PHAMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WILLIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:801-756-2250
Mailing Address - Street 1:5353 W 11000 N
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9403
Mailing Address - Country:US
Mailing Address - Phone:801-756-2250
Mailing Address - Fax:
Practice Address - Street 1:5353 W 11000 N
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-9403
Practice Address - Country:US
Practice Address - Phone:801-756-2250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274777-1703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870309253012Medicaid
UT1168910001Medicare NSC