Provider Demographics
NPI:1821750738
Name:KOHAL PHARMACY INC
Entity Type:Organization
Organization Name:KOHAL PHARMACY INC
Other - Org Name:KOHAL PHARMACY WALLACE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-220-6150
Mailing Address - Street 1:800 BANK ST
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:ID
Mailing Address - Zip Code:83873-2306
Mailing Address - Country:US
Mailing Address - Phone:208-752-1833
Mailing Address - Fax:208-752-1831
Practice Address - Street 1:800 BANK ST
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:ID
Practice Address - Zip Code:83873-2306
Practice Address - Country:US
Practice Address - Phone:208-752-1833
Practice Address - Fax:208-752-1831
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOHAL PHARMACY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-07
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1821750738Medicaid