Provider Demographics
NPI:1174804074
Name:KAMHOLZ, BRIAN LEE (RPH)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LEE
Last Name:KAMHOLZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-2501
Mailing Address - Country:US
Mailing Address - Phone:815-963-3710
Mailing Address - Fax:815-963-1776
Practice Address - Street 1:3803 AUBURN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-2501
Practice Address - Country:US
Practice Address - Phone:815-963-3710
Practice Address - Fax:815-963-1776
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-037671183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist