Provider Demographics
NPI:1386636652
Name:KOHLLS PHARMACY & HOMECARE INC
Entity Type:Organization
Organization Name:KOHLLS PHARMACY & HOMECARE INC
Other - Org Name:KOHLLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOHLL
Authorized Official - Suffix:
Authorized Official - Credentials:
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 1:2923 LEAVENWORTH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-2739
Practice Address - Country:US
Practice Address - Phone:402-342-6547
Practice Address - Fax:402-341-5207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NE2234333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========07Medicaid
NE=========07Medicaid