Provider Demographics
NPI:1902069172
Name:KJ MEDICAL INC
Entity Type:Organization
Organization Name:KJ MEDICAL INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:208-733-9242
Mailing Address - Street 1:615 FILER AVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4008
Mailing Address - Country:US
Mailing Address - Phone:208-733-9242
Mailing Address - Fax:208-733-2810
Practice Address - Street 1:615 FILER AVE
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4008
Practice Address - Country:US
Practice Address - Phone:208-733-9242
Practice Address - Fax:208-733-2810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1260CP332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805009700Medicaid