Healthcare Provider Details

I. General information

NPI: 1275525537
Provider Name (Legal Business Name): KOHLLS PHARMACY & HOMECARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 N 114TH ST
OMAHA NE
68154-1571
US

IV. Provider business mailing address

12759 Q ST
OMAHA NE
68137-3211
US

V. Phone/Fax

Practice location:
  • Phone: 402-408-0012
  • Fax: 402-408-0020
Mailing address:
  • Phone: 402-895-6812
  • Fax: 402-895-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number2239
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2239
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number2239
License Number StateNE
# 4
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2239
License Number StateNE

VIII. Authorized Official

Name: MR. DAVID GEOFFREY KOHLL
Title or Position: PRESIDENT/OWNER
Credential: PHARM. D
Phone: 402-895-6812