Provider Demographics
NPI:1588799902
Name:KOHAL PHARMACY INC
Entity Type:Organization
Organization Name:KOHAL PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECH
Authorized Official - Prefix:
Authorized Official - First Name:SANDALEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORBRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-245-6422
Mailing Address - Street 1:740 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2693
Mailing Address - Country:US
Mailing Address - Phone:208-786-9303
Mailing Address - Fax:208-783-4302
Practice Address - Street 1:740 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2693
Practice Address - Country:US
Practice Address - Phone:208-786-9303
Practice Address - Fax:208-783-4302
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOHAL PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1095CP333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0025279Medicaid