Provider Demographics
NPI:1043520968
Name:KCC, INC
Entity Type:Organization
Organization Name:KCC, INC
Other - Org Name:VITAL CARE RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GILCHRIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-482-4003
Mailing Address - Street 1:1501 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4027
Mailing Address - Country:US
Mailing Address - Phone:601-482-4003
Mailing Address - Fax:601-482-3948
Practice Address - Street 1:8625 LINE AVE STE A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6107
Practice Address - Country:US
Practice Address - Phone:318-673-8360
Practice Address - Fax:318-673-8940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006322-IR332B00000X, 332BP3500X, 3336H0001X
LA6322333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2200429Medicaid
LA0242680004Medicare NSC