Provider Demographics
NPI:1235215542
Name:KMDS INC
Entity Type:Organization
Organization Name:KMDS INC
Other - Org Name:GOODMAN PLAZA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SUDARSANA
Authorized Official - Middle Name:VARMA
Authorized Official - Last Name:UDDARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:718-842-0031
Mailing Address - Street 1:3250 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-6743
Mailing Address - Country:US
Mailing Address - Phone:718-842-0031
Mailing Address - Fax:718-842-0129
Practice Address - Street 1:3250 3RD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-6743
Practice Address - Country:US
Practice Address - Phone:718-842-0031
Practice Address - Fax:718-842-0129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-29
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0251293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3379876OtherPHARMACY NCPDP NUMBER
NY02239169Medicaid
NY02239169Medicaid