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General NPI Number Information
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NPI Number | 1588018212
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Entity Type | Organization
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Legal Business Name | KMART PHARMACY #4062
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Dates
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Enumeration Date | 04/19/2016
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Last Update Date | 04/19/2016
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Provider Practice Location Address
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Address Line | 3311 RIVERSIDE DR
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City | DANVILLE
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State | VA
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Zip | 24541-3430
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Country | US
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Telephone | 434-799-0162
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Fax | 847-396-2798
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Provider Business Mailing Address
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Address Line | 455 SYCAMORE CIR
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City | DANVILLE
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State | VA
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Zip | 24540-5356
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Country | US
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Telephone | 434-791-1733
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | VICKIE ADAMS-LOVELACE
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Credential |
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Telephone | 434-799-0162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 0202011002
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License Number State | VA
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