Healthcare Provider Details

I. General information

NPI: 1801118286
Provider Name (Legal Business Name): KOYAGI ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S WINTER ST
MIDWAY KY
40347
US

IV. Provider business mailing address

106 S WINTER ST
MIDWAY KY
40347
US

V. Phone/Fax

Practice location:
  • Phone: 859-421-9388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP07384
License Number StateKY

VIII. Authorized Official

Name: DR. TAKESHI O KOYAGI
Title or Position: CEO/PRESIDENT
Credential: PHARMD
Phone: 859-421-9388