Provider Demographics
NPI:1497254544
Name:KAK HEALTHCARE, LLC
Entity Type:Organization
Organization Name:KAK HEALTHCARE, LLC
Other - Org Name:PHARM HOUSE DRUG- TRINITY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KUBOSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:797-218-4735
Mailing Address - Street 1:4941 REIGER AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214
Mailing Address - Country:US
Mailing Address - Phone:979-218-4735
Mailing Address - Fax:
Practice Address - Street 1:485 S ROBB ST.
Practice Address - Street 2:STE B
Practice Address - City:TRINITY
Practice Address - State:TX
Practice Address - Zip Code:75862
Practice Address - Country:US
Practice Address - Phone:936-594-3593
Practice Address - Fax:936-594-9681
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KAK HEALTH HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-05
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
TX317623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149789Medicaid
2175858OtherPK