Provider Demographics
NPI:1952666083
Name:KOHS, GORDON (RPH)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:KOHS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:GORDY
Other - Middle Name:
Other - Last Name:KOHS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:3300 124TH AVE NW
Mailing Address - Street 2:TARGET #1144
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3805
Mailing Address - Country:US
Mailing Address - Phone:763-323-8402
Mailing Address - Fax:
Practice Address - Street 1:3300 124TH AVE NW
Practice Address - Street 2:TARGET #1144
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-3805
Practice Address - Country:US
Practice Address - Phone:763-323-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-04
Last Update Date:2012-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN113295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist