Provider Demographics
NPI:1073800314
Name:K2RED LLC
Entity Type:Organization
Organization Name:K2RED LLC
Other - Org Name:JEROME DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/RPH
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FUCHS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-735-8700
Mailing Address - Street 1:111 PIONEER CT STE 2
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-5193
Mailing Address - Country:US
Mailing Address - Phone:208-324-2440
Mailing Address - Fax:208-324-2165
Practice Address - Street 1:111 PIONEER CT STE 2
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-5193
Practice Address - Country:US
Practice Address - Phone:208-324-2440
Practice Address - Fax:208-324-2165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID17019RP3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130826OtherPK