Provider Demographics
NPI:1124678453
Name:KCKLG LLC
Entity type:Organization
Organization Name:KCKLG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAYLANI
Authorized Official - Middle Name:
Authorized Official - Last Name:MACARAEG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-374-7344
Mailing Address - Street 1:6496 MEDICAL CENTER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-2409
Mailing Address - Country:US
Mailing Address - Phone:702-749-7404
Mailing Address - Fax:702-749-7414
Practice Address - Street 1:6496 MEDICAL CENTER ST STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-2409
Practice Address - Country:US
Practice Address - Phone:702-749-7404
Practice Address - Fax:702-749-7414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-18
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy