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General NPI Number Information
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NPI Number | 1912361619
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Entity Type | Organization
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Legal Business Name | KMART PHARMACY 3022
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Dates
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Enumeration Date | 04/08/2016
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Last Update Date | 04/08/2016
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Provider Practice Location Address
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Address Line | 2854 W STATE ST
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City | BRISTOL
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State | TN
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Zip | 37620-1711
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Country | US
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Telephone | 423-968-7032
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Fax | 847-396-2508
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Provider Business Mailing Address
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Address Line | 2854 W STATE ST
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City | BRISTOL
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State | TN
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Zip | 37620-1711
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Country | US
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Telephone | 423-968-7032
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Fax | 847-396-2508
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Authorized Official
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Title or Position | PHARMACIST
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Name | DR. CHARLES EDWIN ROBERTS II
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Credential | PHARM.D
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Telephone | 423-968-7032
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 36205
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License Number State | TN
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