Provider Demographics
NPI:1982927323
Name:KOHANA PHARMACY AND CENTER FOR REGENERATIVE MEDICINE INC
Entity type:Organization
Organization Name:KOHANA PHARMACY AND CENTER FOR REGENERATIVE MEDICINE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:805-542-0864
Mailing Address - Street 1:181 TANK FARM RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7080
Mailing Address - Country:US
Mailing Address - Phone:805-542-0864
Mailing Address - Fax:805-542-0867
Practice Address - Street 1:181 TANK FARM RD STE 120
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7082
Practice Address - Country:US
Practice Address - Phone:805-542-0864
Practice Address - Fax:805-542-0867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CA502643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124185OtherPK