Provider Demographics
NPI:1174630354
Name:KPH HEALTHCARE SERVICES, INC.
Entity Type:Organization
Organization Name:KPH HEALTHCARE SERVICES, INC.
Other - Org Name:KINNEY DRUGS #24
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-287-3600
Mailing Address - Street 1:29 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1401
Mailing Address - Country:US
Mailing Address - Phone:315-287-3600
Mailing Address - Fax:315-287-4291
Practice Address - Street 1:3873 ROME RD
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-2488
Practice Address - Country:US
Practice Address - Phone:315-298-2024
Practice Address - Fax:315-298-7756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004724333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00561968Medicaid
3343162OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY00561968Medicaid