Provider Demographics
NPI:1053453910
Name:KOHAL PHARMACY INC
Entity Type:Organization
Organization Name:KOHAL PHARMACY INC
Other - Org Name:KOHAL PHARMACY INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-682-4015
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:ID
Mailing Address - Zip Code:83850-0400
Mailing Address - Country:US
Mailing Address - Phone:208-682-3920
Mailing Address - Fax:208-682-3939
Practice Address - Street 1:504 N DIVISION AVE
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:ID
Practice Address - Zip Code:83850
Practice Address - Country:US
Practice Address - Phone:208-682-3920
Practice Address - Fax:208-682-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID857CP333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0025278Medicaid