Healthcare Provider Details

I. General information

NPI: 1982033429
Provider Name (Legal Business Name): KENNETH TROY KOCH PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 N TAYLOR AVE
OAK PARK IL
60302-2526
US

IV. Provider business mailing address

216 N TAYLOR AVE
OAK PARK IL
60302-2526
US

V. Phone/Fax

Practice location:
  • Phone: 708-545-8833
  • Fax:
Mailing address:
  • Phone: 708-545-8833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number011159
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.296889
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: