Provider Demographics
NPI:1972915189
Name:KINGDOM PHARMACY LLC
Entity Type:Organization
Organization Name:KINGDOM PHARMACY LLC
Other - Org Name:KINGDOM PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUAHOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-455-7915
Mailing Address - Street 1:9014 W CHESTER PIKE
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-2606
Mailing Address - Country:US
Mailing Address - Phone:484-455-7915
Mailing Address - Fax:484-455-7923
Practice Address - Street 1:9014 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2606
Practice Address - Country:US
Practice Address - Phone:484-455-7915
Practice Address - Fax:484-455-7923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4824803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029193710001Medicaid
2145885OtherPK