Provider Demographics
NPI:1073067278
Name:KMART PHARMACY
Entity Type:Organization
Organization Name:KMART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEEPAK
Authorized Official - Middle Name:
Authorized Official - Last Name:KINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-396-2040
Mailing Address - Street 1:161 BIG ELK MALL
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5912
Mailing Address - Country:US
Mailing Address - Phone:410-392-6315
Mailing Address - Fax:
Practice Address - Street 1:161 BIG ELK MALL
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5912
Practice Address - Country:US
Practice Address - Phone:410-392-6315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD243323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy