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General NPI Number Information
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NPI Number | 1851754873
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Entity Type | Organization
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Legal Business Name | K MART PHARMACY #9354
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Dates
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Enumeration Date | 03/29/2016
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Last Update Date | 03/29/2016
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Provider Practice Location Address
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Address Line | 430 W RIDGE RD
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City | GRIFFITH
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State | IN
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Zip | 46319-1018
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Country | US
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Telephone | 219-972-0364
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Fax | 847-396-3229
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Provider Business Mailing Address
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Address Line | 430 W RIDGE RD
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City | GRIFFITH
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State | IN
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Zip | 46319-1018
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Country | US
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Telephone | 219-972-0364
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Fax | 847-396-3229
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Authorized Official
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Title or Position | PHARMACIST
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Name | WILLIAM TRZASKUS
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Credential | RPH
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Telephone | 219-972-0364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 26023951A
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License Number State | IN
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