Provider Demographics
NPI:1306113816
Name:KOHLER, KIM G (RPH)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:G
Last Name:KOHLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3044
Mailing Address - Country:US
Mailing Address - Phone:208-522-4655
Mailing Address - Fax:208-522-6670
Practice Address - Street 1:1850 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3044
Practice Address - Country:US
Practice Address - Phone:208-522-4655
Practice Address - Fax:208-522-6670
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4157183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist