Provider Demographics
NPI:1851754873
Name:K MART PHARMACY #9354
Entity Type:Organization
Organization Name:K MART PHARMACY #9354
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:TRZASKUS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:219-972-0364
Mailing Address - Street 1:430 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-1018
Mailing Address - Country:US
Mailing Address - Phone:219-972-0364
Mailing Address - Fax:847-396-3229
Practice Address - Street 1:430 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1018
Practice Address - Country:US
Practice Address - Phone:219-972-0364
Practice Address - Fax:847-396-3229
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
IN26023951A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy