Provider Demographics
NPI:1366811630
Name:KMG PHARMACY LLC
Entity type:Organization
Organization Name:KMG PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AO, PHCY MANAGER.
Authorized Official - Prefix:
Authorized Official - First Name:MAHMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALTAF
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:937-829-1012
Mailing Address - Street 1:846 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2911
Mailing Address - Country:US
Mailing Address - Phone:937-529-4433
Mailing Address - Fax:937-715-4447
Practice Address - Street 1:846 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2911
Practice Address - Country:US
Practice Address - Phone:937-529-4433
Practice Address - Fax:937-715-4447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X
OH0225321003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0146319Medicaid
2152395OtherPK