Provider Demographics
NPI:1851400824
Name:KUBAT PHARMACY, LLC
Entity type:Organization
Organization Name:KUBAT PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-315-1944
Mailing Address - Street 1:4924 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-3219
Mailing Address - Country:US
Mailing Address - Phone:402-558-8888
Mailing Address - Fax:402-558-7388
Practice Address - Street 1:2401 N ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-2708
Practice Address - Country:US
Practice Address - Phone:402-731-4333
Practice Address - Fax:402-734-8824
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERCIPIO KP HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-30
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 333600000X, 3336M0002X, 3336S0011X
NE27383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025435200Medicaid
2817318OtherNCPDP
2055909OtherPK
NE47048968700Medicaid