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NPI Code Detail

MEDICARE: KDTK

MEDICARE: KDTK
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
1333600000XPharmacy
23336C0003XCommunity/Retail PharmacyPH02657NV

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12126219OTHERPK
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1528368990
Entity Type Code : Organization
Provider Name (Legal Business Name) : KDTK
Provider Business Mailing Address
First Line : 6820 W CHEYENNE AVE
Second Line :
City : LAS VEGAS
State : NV
Zip : 89108-4590
Country : US
Telephone Number : 702-436-5279
Fax Number : 702-776-8201
Provider Business Practice Location Address
First Line : 6820 W CHEYENNE AVE
Second Line :
City : LAS VEGAS
State : NV
Zip : 89108-4590
Country : US
Telephone Number : 702-436-5279
Fax Number : 702-776-8201
Authorized Official
Title or Position : PHARMACY DIRECTOR & PIC
Name : KHANH PHAM
Credential : RPH
Telephone Number : 702-436-5279
Provider Enumeration Date : 11/01/2010
Last Update Date : 01/15/2020

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Directions to “KDTK ” Practice Location

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