Provider Demographics
NPI:1275525537
Name:KOHLLS PHARMACY & HOMECARE INC
Entity Type:Organization
Organization Name:KOHLLS PHARMACY & HOMECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEOFFREY
Authorized Official - Last Name:KOHLL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:402-895-6812
Mailing Address - Street 1:12759 Q ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3211
Mailing Address - Country:US
Mailing Address - Phone:402-895-6812
Mailing Address - Fax:402-895-7655
Practice Address - Street 1:622 N 114TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-1571
Practice Address - Country:US
Practice Address - Phone:402-408-0012
Practice Address - Fax:402-408-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2239332B00000X, 332BP3500X, 333600000X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========-00Medicaid
0233100006Medicare NSC