Provider Demographics
NPI:1346647617
Name:KALKASKA MEMORIAL HEALTH CENTER
Entity Type:Organization
Organization Name:KALKASKA MEMORIAL HEALTH CENTER
Other - Org Name:KALKASKA MEMORIAL HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT-CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROGOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-258-7501
Mailing Address - Street 1:419 S CORAL ST
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-2503
Mailing Address - Country:US
Mailing Address - Phone:231-258-7790
Mailing Address - Fax:231-258-7756
Practice Address - Street 1:419 S CORAL ST
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-2503
Practice Address - Country:US
Practice Address - Phone:231-258-7790
Practice Address - Fax:231-258-7756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010002993336C0003X, 3336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1556877Medicaid
MIAK8032687OtherDEA NUMBER