Provider Demographics
NPI:1386057677
Name:KMART PHARMACY
Entity type:Organization
Organization Name:KMART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DISTRCIT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-544-3086
Mailing Address - Street 1:1284 BRICE RD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2311
Mailing Address - Country:US
Mailing Address - Phone:614-864-3636
Mailing Address - Fax:
Practice Address - Street 1:1284 BRICE RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2311
Practice Address - Country:US
Practice Address - Phone:614-864-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH031322133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy