Provider Demographics
NPI:1043461353
Name:KVG ENTERPRISES INC
Entity Type:Organization
Organization Name:KVG ENTERPRISES INC
Other - Org Name:RANDOL MILL LTC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-274-1883
Mailing Address - Street 1:1014 A NORTH FIELDER ROAD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1014 A NORTH FIELDER ROAD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015
Practice Address - Country:US
Practice Address - Phone:817-274-1883
Practice Address - Fax:817-274-9621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332100000X, 3336I0012X
TX195433336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332100000XSuppliersDepartment of Veterans Affairs (VA) Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4549854OtherNCPDP PROVIDER IDENTIFICATION NUMBER