=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063057701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. GLEN JAMES KOHNZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2019
-----------------------------------------------------
Last Update Date | 11/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 N STRATFORD RD
-----------------------------------------------------
City | MOSES LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98837-3512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-765-8979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1921 LEGENDARY LN SE
-----------------------------------------------------
City | EAST WENATCHEE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98802-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-789-0308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PH60928071
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------