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General NPI Number Information
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NPI Number | 1992107874
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Entity Type | Organization
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Legal Business Name | KMART
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Dates
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Enumeration Date | 09/22/2014
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Last Update Date | 09/22/2014
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Provider Practice Location Address
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Address Line | 6531 MACCORKLE AVE SE
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City | CHARLESTON
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State | WV
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Zip | 25304-2921
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Country | US
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Telephone | 304-925-4721
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Fax |
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Provider Business Mailing Address
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Address Line | 6531 MACCORKLE AVE SE
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City | CHARLESTON
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State | WV
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Zip | 25304-2921
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHARMACIST
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Name | ANDREW SCOTT
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Credential |
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Telephone | 304-588-3553
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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 | RP0008667
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License Number State | WV
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