Healthcare Provider Details

I. General information

NPI: 1255737714
Provider Name (Legal Business Name): DAVID KOCH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 11/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2949 SHELDON DR
OSHKOSH WI
54904-8817
US

IV. Provider business mailing address

2949 SHELDON DR
OSHKOSH WI
54904-8817
US

V. Phone/Fax

Practice location:
  • Phone: 920-233-6471
  • Fax:
Mailing address:
  • Phone: 920-233-6471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number9711-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: