Healthcare Provider Details

I. General information

NPI: 1104236843
Provider Name (Legal Business Name): KMART PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2014
Last Update Date: 05/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 E PINE ST
DEMING NM
88030-7038
US

IV. Provider business mailing address

1205 E PINE ST
DEMING NM
88030-7038
US

V. Phone/Fax

Practice location:
  • Phone: 575-544-9008
  • Fax: 575-544-4465
Mailing address:
  • Phone: 575-544-9008
  • Fax: 575-544-4465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberRP00007752
License Number StateNM

VIII. Authorized Official

Name: MR. AMBRISH N PATEL
Title or Position: PHARMACY MANAGER
Credential: PHARMD
Phone: 405-370-4669