Provider Demographics
NPI:1104236843
Name:KMART PHARMACY
Entity type:Organization
Organization Name:KMART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMBRISH
Authorized Official - Middle Name:N
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-370-4669
Mailing Address - Street 1:1205 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:DEMING
Mailing Address - State:NM
Mailing Address - Zip Code:88030-7038
Mailing Address - Country:US
Mailing Address - Phone:575-544-9008
Mailing Address - Fax:575-544-4465
Practice Address - Street 1:1205 E PINE ST
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-7038
Practice Address - Country:US
Practice Address - Phone:575-544-9008
Practice Address - Fax:575-544-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-03
Last Update Date:2014-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP000077523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1619908753OtherPHARMACY NPI NUMBER