Provider Demographics
NPI:1063443117
Name:TRANSFORM KM LLC
Entity Type:Organization
Organization Name:TRANSFORM KM LLC
Other - Org Name:KMART PHARMACY3829
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DVP OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SPEARES LEHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-286-5116
Mailing Address - Street 1:3333 BEVERLY RD # BC260A
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60179-0001
Mailing Address - Country:US
Mailing Address - Phone:847-286-4089
Mailing Address - Fax:847-747-1553
Practice Address - Street 1:4605 TUTU PARK MALL STE 100
Practice Address - Street 2:
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-1736
Practice Address - Country:US
Practice Address - Phone:340-777-3847
Practice Address - Fax:847-396-2717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
VI1-6205-1L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI7748430011OtherMEDICARE NSC
VIPHC150OtherMEDICARE IMU
VI1021Medicaid
P00151733Medicare PIN