Provider Demographics
NPI:1659813251
Name:GKN RX
Entity Type:Organization
Organization Name:GKN RX
Other - Org Name:GKN RX INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KADIYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-392-1958
Mailing Address - Street 1:1471 B ST
Mailing Address - Street 2:SUITE R
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1432
Mailing Address - Country:US
Mailing Address - Phone:209-398-2035
Mailing Address - Fax:209-398-2037
Practice Address - Street 1:1471 B ST STE R
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1426
Practice Address - Country:US
Practice Address - Phone:209-398-2035
Practice Address - Fax:209-398-2037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-14
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA515663336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166230OtherPK
CA1114351467Medicaid
CA1114351467Medicaid