Healthcare Provider Details

I. General information

NPI: 1003183815
Provider Name (Legal Business Name): CHARLES E KOCH JR. PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 NEW HOLLAND AVE
LANCASTER PA
17601-5606
US

IV. Provider business mailing address

1110 ENTERPRISE RD, SUITE C
EAST PETERSBURG PA
17520-4340
US

V. Phone/Fax

Practice location:
  • Phone: 717-544-3590
  • Fax: 717-544-3610
Mailing address:
  • Phone: 717-925-2390
  • Fax: 717-925-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP438674
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: