Provider Demographics
NPI:1790148492
Name:KMART PHARMACY
Entity Type:Organization
Organization Name:KMART PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DISTRICT MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-361-3649
Mailing Address - Street 1:2110 S M 76
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-8737
Mailing Address - Country:US
Mailing Address - Phone:989-345-4884
Mailing Address - Fax:847-396-2732
Practice Address - Street 1:2110 S M 76
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-8737
Practice Address - Country:US
Practice Address - Phone:989-345-4884
Practice Address - Fax:847-396-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301005457333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy