Healthcare Provider Details

I. General information

NPI: 1558478735
Provider Name (Legal Business Name): KPH HEALTHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/04/2024
Certification Date: 07/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

868 STATE ROUTE 11
CHAMPLAIN NY
12919-3131
US

IV. Provider business mailing address

29 E MAIN ST
GOUVERNEUR NY
13642-1401
US

V. Phone/Fax

Practice location:
  • Phone: 518-299-5466
  • Fax: 518-299-5467
Mailing address:
  • Phone: 315-287-3600
  • Fax: 315-287-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number023691
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01832246
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier3328259
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER

VIII. Authorized Official

Name: ELIZABETH M MARLOW
Title or Position: THIRD PARTY ADMINISTRATOR
Credential:
Phone: 315-287-3600