Provider Demographics
NPI:1922148469
Name:KIMRO INC
Entity Type:Organization
Organization Name:KIMRO INC
Other - Org Name:KIMROS MEDICINE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-393-6290
Mailing Address - Street 1:511 STATE ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2672
Mailing Address - Country:US
Mailing Address - Phone:315-393-6290
Mailing Address - Fax:315-394-0021
Practice Address - Street 1:511 STATE ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2672
Practice Address - Country:US
Practice Address - Phone:315-393-6290
Practice Address - Fax:315-394-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0200343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00899330Medicaid
2062381OtherPK
0129570001Medicare NSC
NY00899330Medicaid