Healthcare Provider Details

I. General information

NPI: 1013203074
Provider Name (Legal Business Name): KPH HEALTHCARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 CHURCH ST
BARTON VT
05822-8511
US

IV. Provider business mailing address

29 E MAIN ST
GOUVERNEUR NY
13642-1401
US

V. Phone/Fax

Practice location:
  • Phone: 802-525-4098
  • Fax: 802-525-3794
Mailing address:
  • Phone: 315-287-3600
  • Fax: 315-287-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0380077454RPPP
License Number StateVT

VIII. Authorized Official

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