Provider Demographics
NPI:1568832517
Name:KMART PHARMACY
Entity Type:Organization
Organization Name:KMART PHARMACY
Other - Org Name:SEARS HOLDINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DISTRICT MANAGER-SOUTHERN REGION
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, DM
Authorized Official - Phone:941-504-1447
Mailing Address - Street 1:2070 ENVOY CT
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-2560
Mailing Address - Country:US
Mailing Address - Phone:727-709-4549
Mailing Address - Fax:847-396-2725
Practice Address - Street 1:26996 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3466
Practice Address - Country:US
Practice Address - Phone:727-796-1033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:I DONT KNOW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS29426251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare