MEDICARE: KMART

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P2201X	Ambulatory Care Pharmacist	03109283	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	03109283	OTHER		PHARMACIST
2	03109283	OTHER	OH	PHARMACIST

General Provider Information

NPI Number	:	1235583782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMART

Provider Business Mailing Address
First Line	:	1801 W ALEXIS RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43613-2302
Country	:	US
Telephone Number	:	419-473-0206
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 W ALEXIS RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43613-2302
Country	:	US
Telephone Number	:	419-473-0206
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST
Name	:	ROBERT O URFER
Credential	:
Telephone Number	:	419-473-0206

Provider Enumeration Date	:	04/21/2016
Last Update Date	:	04/21/2016

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Directions to “KMART ” Practice Location

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