Provider Demographics
NPI:1912361619
Name:KMART PHARMACY 3022
Entity Type:Organization
Organization Name:KMART PHARMACY 3022
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:II
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:423-968-7032
Mailing Address - Street 1:2854 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1711
Mailing Address - Country:US
Mailing Address - Phone:423-968-7032
Mailing Address - Fax:847-396-2508
Practice Address - Street 1:2854 W STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1711
Practice Address - Country:US
Practice Address - Phone:423-968-7032
Practice Address - Fax:847-396-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty