Provider Demographics
NPI:1649384637
Name:MIKOSH DRUG COMPANY, LLC
Entity Type:Organization
Organization Name:MIKOSH DRUG COMPANY, LLC
Other - Org Name:COMFORT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:DR
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIKOSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:830-995-3300
Mailing Address - Street 1:404 HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:COMFORT
Mailing Address - State:TX
Mailing Address - Zip Code:78013-2173
Mailing Address - Country:US
Mailing Address - Phone:830-995-3300
Mailing Address - Fax:830-995-4635
Practice Address - Street 1:404 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:COMFORT
Practice Address - State:TX
Practice Address - Zip Code:78013-2173
Practice Address - Country:US
Practice Address - Phone:830-995-3300
Practice Address - Fax:830-428-0239
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIKOSH DRUG COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-18
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX284493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139717OtherPK
TX146756Medicaid