Provider Demographics
NPI:1215223755
Name:KODO PHARMACY INC
Entity Type:Organization
Organization Name:KODO PHARMACY INC
Other - Org Name:KODO PHARMACY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KODIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-727-4721
Mailing Address - Street 1:1522 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60433-1365
Mailing Address - Country:US
Mailing Address - Phone:815-727-4721
Mailing Address - Fax:815-727-7839
Practice Address - Street 1:1522 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60433-1365
Practice Address - Country:US
Practice Address - Phone:815-727-4721
Practice Address - Fax:815-727-7839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-23
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X, 3336S0011X
IL0540176953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1485716OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IL=========001Medicaid
IL=========001Medicaid