Provider Demographics
NPI:1073679684
Name:KLH ENTERPRISES, INC.
Entity Type:Organization
Organization Name:KLH ENTERPRISES, INC.
Other - Org Name:ST. MARY'S ROAD PHARMACY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LYDELL
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-685-1845
Mailing Address - Street 1:111 N OAKLEY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-4476
Mailing Address - Country:US
Mailing Address - Phone:706-685-1845
Mailing Address - Fax:706-685-9066
Practice Address - Street 1:111 N OAKLEY DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-4476
Practice Address - Country:US
Practice Address - Phone:706-685-1845
Practice Address - Fax:706-685-9066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0087783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA265721575AMedicaid
GA265721575AMedicaid