Provider Demographics
NPI:1124456884
Name:KMART
Entity type:Organization
Organization Name:KMART
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELECHI
Authorized Official - Middle Name:A
Authorized Official - Last Name:AGUWA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:240-994-3121
Mailing Address - Street 1:613 FIRST NATIONAL ST
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-3329
Mailing Address - Country:US
Mailing Address - Phone:240-994-3121
Mailing Address - Fax:
Practice Address - Street 1:613 FIRST NATIONAL ST
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-3329
Practice Address - Country:US
Practice Address - Phone:240-994-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI530241688305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service