MEDICARE: KOHLLS PHARMACY & HOMECARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy	2234	NE

General Provider Information

NPI Number	:	1386636652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOHLLS PHARMACY & HOMECARE INC

Provider Business Mailing Address
First Line	:	12759 Q ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68137-3211
Country	:	US
Telephone Number	:	402-895-6812
Fax Number	:	402-895-7655

Provider Business Practice Location Address
First Line	:	2923 LEAVENWORTH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68105-2739
Country	:	US
Telephone Number	:	402-342-6547
Fax Number	:	402-341-5207

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID G KOHLL
Credential	:
Telephone Number	:	402-895-6812

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	01/23/2009

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