Provider Demographics
NPI:1437512241
Name:KMART PHARMACY
Entity Type:Organization
Organization Name:KMART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:LANETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SCARAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-395-2329
Mailing Address - Street 1:4701 W TILGHMAN ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-3211
Mailing Address - Country:US
Mailing Address - Phone:610-395-2329
Mailing Address - Fax:847-396-2871
Practice Address - Street 1:4701 W TILGHMAN ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-3211
Practice Address - Country:US
Practice Address - Phone:610-395-2329
Practice Address - Fax:847-396-2871
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEARS HOLDINGS CO.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP034253L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007662280108Medicaid