=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992893697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS PAUL KOCH R. PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 COMANCHE RD
-----------------------------------------------------
City | FORT MEADE
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57741-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-347-2511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 619 ENGLEWOOD CT
-----------------------------------------------------
City | SPEARFISH
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57783-1118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-722-5122
-----------------------------------------------------
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 | 12310
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------