Provider Demographics
NPI:1275734972
Name:KMART
Entity Type:Organization
Organization Name:KMART
Other - Org Name:SEARS HOLDINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY INTERN
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:954-438-0705
Mailing Address - Street 1:10020 SHERIDAN ST
Mailing Address - Street 2:8309
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-8555
Mailing Address - Country:US
Mailing Address - Phone:954-443-1028
Mailing Address - Fax:
Practice Address - Street 1:10501 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026
Practice Address - Country:US
Practice Address - Phone:954-438-8822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty