MEDICARE: KMART PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	24332	MD

General Provider Information

NPI Number	:	1073067278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMART PHARMACY

Provider Business Mailing Address
First Line	:	161 BIG ELK MALL
Second Line	:
City	:	ELKTON
State	:	MD
Zip	:	21921-5912
Country	:	US
Telephone Number	:	410-392-6315
Fax Number	:

Provider Business Practice Location Address
First Line	:	161 BIG ELK MALL
Second Line	:
City	:	ELKTON
State	:	MD
Zip	:	21921-5912
Country	:	US
Telephone Number	:	410-392-6315
Fax Number	:

Authorized Official
Title or Position	:	DISTRICT MANAGER
Name	:	DEEPAK KINI
Credential	:
Telephone Number	:	847-396-2040

Provider Enumeration Date	:	08/05/2016
Last Update Date	:	08/05/2016

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Directions to “KMART PHARMACY ” Practice Location

Language	Start Address	Practice Location

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