Healthcare Provider Details

I. General information

NPI: 1700161783
Provider Name (Legal Business Name): JIM J KOCOLAS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2011
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 HARROW CT
MODESTO CA
95350-1425
US

IV. Provider business mailing address

309 HARROW CT
MODESTO CA
95350-1425
US

V. Phone/Fax

Practice location:
  • Phone: 209-523-4162
  • Fax: 209-522-2409
Mailing address:
  • Phone: 209-523-4162
  • Fax: 209-522-2409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number27675
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number05824
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: