1104236843 NPI number — KMART PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104236843 NPI number — KMART PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KMART PHARMACY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104236843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 E PINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMING
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88030-7038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-544-9008
Provider Business Mailing Address Fax Number:
575-544-4465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 E PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMING
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88030-7038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-544-9008
Provider Business Practice Location Address Fax Number:
575-544-4465
Provider Enumeration Date:
05/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
AMBRISH
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
405-370-4669

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  RP00007752 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1619908753 . This is a "PHARMACY NPI NUMBER" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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