Provider Demographics
NPI:1891159976
Name:KMART PHRAMACY
Entity Type:Organization
Organization Name:KMART PHRAMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SEYED
Authorized Official - Middle Name:ABOTALEB
Authorized Official - Last Name:ALAVI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-568-0470
Mailing Address - Street 1:206 S GOLFWOOD DR W
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81007-3674
Mailing Address - Country:US
Mailing Address - Phone:719-568-0470
Mailing Address - Fax:847-369-2896
Practice Address - Street 1:3415 N ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1156
Practice Address - Country:US
Practice Address - Phone:719-545-0707
Practice Address - Fax:847-396-2896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0013355305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service