Provider Demographics
NPI:1588162960
Name:KAKS HEALTHCARE, LLC
Entity type:Organization
Organization Name:KAKS HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KUBOSH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:979-218-4735
Mailing Address - Street 1:4941 REIGER AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214
Mailing Address - Country:US
Mailing Address - Phone:979-218-4735
Mailing Address - Fax:
Practice Address - Street 1:110 E TRAVIS ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-2615
Practice Address - Country:US
Practice Address - Phone:979-968-5835
Practice Address - Fax:979-968-8580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX317663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175714OtherPK
TX149786Medicaid