Provider Demographics
NPI:1295832574
Name:K2RED L.L.C.
Entity Type:Organization
Organization Name:K2RED L.L.C.
Other - Org Name:DICK'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FUCHS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-734-7373
Mailing Address - Street 1:526 SHOUP AVE W STE K
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5050
Mailing Address - Country:US
Mailing Address - Phone:208-734-7373
Mailing Address - Fax:208-734-7389
Practice Address - Street 1:526 SHOUP AVE W STE K
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-734-7373
Practice Address - Fax:208-734-7389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1307CP332B00000X, 3336C0003X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805156900Medicaid
ID805182800Medicaid
ID805156900Medicaid