Provider Demographics
NPI:1821079617
Name:KMN PHARMACY CORP
Entity Type:Organization
Organization Name:KMN PHARMACY CORP
Other - Org Name:OVAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-654-2200
Mailing Address - Street 1:255 E GUN HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2109
Mailing Address - Country:US
Mailing Address - Phone:718-654-2200
Mailing Address - Fax:718-515-9118
Practice Address - Street 1:255 E GUN HILL RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2109
Practice Address - Country:US
Practice Address - Phone:718-654-2200
Practice Address - Fax:718-515-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024537332B00000X, 3336C0003X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01932829Medicaid
3302421OtherOTHER ID NUMBER
1291520001Medicare NSC
A300059348Medicare PIN