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General NPI Number Information
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NPI Number | 1366811630
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Entity Type | Organization
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Legal Business Name | KMG PHARMACY LLC
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Dates
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Enumeration Date | 09/17/2015
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Last Update Date | 08/17/2024
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Provider Practice Location Address
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Address Line | 846 E MAIN ST
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City | TROTWOOD
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State | OH
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Zip | 45426-2911
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Country | US
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Telephone | 937-529-4433
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Fax | 937-715-4447
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Provider Business Mailing Address
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Address Line | 846 E MAIN ST
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City | TROTWOOD
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State | OH
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Zip | 45426-2911
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Country | US
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Telephone | 937-529-4433
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Fax | 937-715-4447
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Authorized Official
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Title or Position | OWNER, AO, PHCY MANAGER.
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Name | MAHMOUD SHALTAF
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Credential | DR
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Telephone | 937-829-1012
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 022532100
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License Number State | OH
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