Provider Demographics
NPI:1285012138
Name:KMART3425
Entity Type:Organization
Organization Name:KMART3425
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:606-920-9933
Mailing Address - Street 1:5636 US ROUTE 60
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2148
Mailing Address - Country:US
Mailing Address - Phone:304-736-2098
Mailing Address - Fax:
Practice Address - Street 1:5636 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2148
Practice Address - Country:US
Practice Address - Phone:304-736-2098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007348333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy