Provider Demographics
NPI:1407033855
Name:KUBAT CUSTOM HEALTH CARE, LLC
Entity Type:Organization
Organization Name:KUBAT CUSTOM HEALTH CARE, LLC
Other - Org Name:KUBAT CUSTOM HEALTH CARE, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-315-1944
Mailing Address - Street 1:4924 CENTER ST STE A1
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-3219
Mailing Address - Country:US
Mailing Address - Phone:402-558-2474
Mailing Address - Fax:402-561-1252
Practice Address - Street 1:4924 CENTER ST STE A1
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-3219
Practice Address - Country:US
Practice Address - Phone:402-558-2474
Practice Address - Fax:402-561-1252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERCIPIO KP HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-29
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47048968700Medicaid
2818156OtherNCPDP
2129910OtherPK