Healthcare Provider Details

I. General information

NPI: 1821134958
Provider Name (Legal Business Name): KOTZEBUE DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 04/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N SAINT JOSEPH ST
GONZALES TX
78629-4019
US

IV. Provider business mailing address

525 N SAINT JOSEPH ST
GONZALES TX
78629-4019
US

V. Phone/Fax

Practice location:
  • Phone: 830-672-8505
  • Fax: 830-672-8507
Mailing address:
  • Phone: 830-672-8505
  • Fax: 830-672-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number04194
License Number StateTX

VIII. Authorized Official

Name: DOUG KOTZEBUE
Title or Position: OWNER AND PIC
Credential: RPH
Phone: 830-672-8505