=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811004096
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KPH HEALTHCARE SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 07/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7395 UTICA BLVD
-----------------------------------------------------
City | LOWVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13367-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-302-5466
-----------------------------------------------------
Fax | 315-302-5467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 E MAIN ST
-----------------------------------------------------
City | GOUVERNEUR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13642-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-287-3600
-----------------------------------------------------
Fax | 315-287-4291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THIRD PARTY ADMINISTRATOR
-----------------------------------------------------
Name | ELIZABETH M MARLOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-287-3600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 013967
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------