Provider Demographics
NPI:1982033429
Name:KOCH, KENNETH TROY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:TROY
Last Name:KOCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 N TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2526
Mailing Address - Country:US
Mailing Address - Phone:708-545-8833
Mailing Address - Fax:
Practice Address - Street 1:216 N TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2526
Practice Address - Country:US
Practice Address - Phone:708-545-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY011159183500000X
IL051.296889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist