Healthcare Provider Details

I. General information

NPI: 1235112954
Provider Name (Legal Business Name): KHK OPERATING CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 BROADWAY
MONTICELLO NY
12701-1732
US

IV. Provider business mailing address

458 BROADWAY
MONTICELLO NY
12701-1732
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-5757
  • Fax: 845-794-3570
Mailing address:
  • Phone: 845-794-5757
  • Fax: 845-794-3570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number021919
License Number StateNY

VIII. Authorized Official

Name: MR. EMIL MOTL
Title or Position: SUPERVISING PHARMACIST
Credential:
Phone: 845-794-5757