Provider Demographics
NPI:1639202609
Name:KOHAL PHARMACY INC
Entity Type:Organization
Organization Name:KOHAL PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:KOHAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-682-4015
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:ID
Mailing Address - Zip Code:83850-0400
Mailing Address - Country:US
Mailing Address - Phone:208-682-4015
Mailing Address - Fax:208-682-3939
Practice Address - Street 1:504 NORTH DIVISION AVE
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:ID
Practice Address - Zip Code:83850
Practice Address - Country:US
Practice Address - Phone:208-682-4015
Practice Address - Fax:208-682-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID857CP332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002528000Medicaid
ID002528000Medicaid