Provider Demographics
NPI:1063057701
Name:KOHNZ, GLEN JAMES
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:JAMES
Last Name:KOHNZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 LEGENDARY LN SE
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-9401
Mailing Address - Country:US
Mailing Address - Phone:618-789-0308
Mailing Address - Fax:
Practice Address - Street 1:1005 N STRATFORD RD
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-3512
Practice Address - Country:US
Practice Address - Phone:509-765-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60928071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist