Provider Demographics
NPI:1790148617
Name:KMART 4062
Entity Type:Organization
Organization Name:KMART 4062
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-799-0162
Mailing Address - Street 1:3710 TOM FORK RD
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:VA
Mailing Address - Zip Code:24586-3844
Mailing Address - Country:US
Mailing Address - Phone:434-822-5873
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:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010116333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy