Provider Demographics
NPI:1528368990
Name:KDTK
Entity Type:Organization
Organization Name:KDTK
Other - Org Name:DOLCRX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY DIRECTOR & PIC
Authorized Official - Prefix:
Authorized Official - First Name:KHANH
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:702-436-5279
Mailing Address - Street 1:6820 W CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4590
Mailing Address - Country:US
Mailing Address - Phone:702-436-5279
Mailing Address - Fax:702-776-8201
Practice Address - Street 1:6820 W CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4590
Practice Address - Country:US
Practice Address - Phone:702-436-5279
Practice Address - Fax:702-776-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NVPH026573336C0003X
NV183500000X1835P1200X
NV1835P1200X1835P1200X
NV3336C0003X3336C0003X
NV3336S0011X3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No333600000XSuppliersPharmacyGroup - Single Specialty
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126219OtherPK
NV1528368990Medicaid