Provider Demographics
NPI:1740599893
Name:KOHLL'S PHARMACY & HOMECARE INC
Entity Type:Organization
Organization Name:KOHLL'S PHARMACY & HOMECARE INC
Other - Org Name:PREVENTATIVE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOHLL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:402-108-0012
Mailing Address - Street 1:12741 Q ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3211
Mailing Address - Country:US
Mailing Address - Phone:402-895-6812
Mailing Address - Fax:402-895-7655
Practice Address - Street 1:12741 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3211
Practice Address - Country:US
Practice Address - Phone:402-895-6812
Practice Address - Fax:402-895-7655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-06
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty