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General NPI Number Information
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NPI Number | 1124456884
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Entity Type | Organization
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Legal Business Name | KMART
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Dates
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Enumeration Date | 10/16/2013
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Last Update Date | 10/16/2013
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Provider Practice Location Address
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Address Line | 613 FIRST NATIONAL ST
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City | IRONWOOD
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State | MI
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Zip | 49938-3329
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Country | US
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Telephone | 240-994-3121
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Fax |
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Provider Business Mailing Address
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Address Line | 613 FIRST NATIONAL ST
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City | IRONWOOD
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State | MI
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Zip | 49938-3329
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Country | US
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Telephone | 240-994-3121
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Fax |
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Authorized Official
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Title or Position | PHARMACY MANAGER
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Name | DR. KELECHI A AGUWA
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Credential | PHARMD
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Telephone | 240-994-3121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 530241688
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License Number State | MI
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