Healthcare Provider Details

I. General information

NPI: 1104430750
Provider Name (Legal Business Name): KSH RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/05/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2442 LILLIAN MILLER PKWY STE 115
DENTON TX
76205-2902
US

IV. Provider business mailing address

2442 LILLIAN MILLER PKWY STE 115
DENTON TX
76205-2902
US

V. Phone/Fax

Practice location:
  • Phone: 940-536-0460
  • Fax: 940-536-0461
Mailing address:
  • Phone: 940-536-0460
  • Fax: 940-536-0461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEAN MICHEL MUDIAY
Title or Position: OFFICER
Credential:
Phone: 682-234-7049