Provider Demographics
NPI:1518558881
Name:KOEHN, MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KOEHN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W PALM ST
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77418-1361
Mailing Address - Country:US
Mailing Address - Phone:979-865-3696
Mailing Address - Fax:
Practice Address - Street 1:250 W PALM ST
Practice Address - Street 2:
Practice Address - City:BELLVILLE
Practice Address - State:TX
Practice Address - Zip Code:77418-1361
Practice Address - Country:US
Practice Address - Phone:979-865-3696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist