Provider Demographics
NPI:1588018212
Name:KMART PHARMACY #4062
Entity Type:Organization
Organization Name:KMART PHARMACY #4062
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS-LOVELACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-799-0162
Mailing Address - Street 1:455 SYCAMORE CIR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-5356
Mailing Address - Country:US
Mailing Address - Phone:434-791-1733
Mailing Address - Fax:
Practice Address - Street 1:3311 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-3430
Practice Address - Country:US
Practice Address - Phone:434-799-0162
Practice Address - Fax:847-396-2798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011002333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy