MEDICARE: KPH HEALTHCARE SERVICES, INC.

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	333600000X	Pharmacy	020545	NY
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3395705	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1508973785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KPH HEALTHCARE SERVICES, INC.

Provider Business Mailing Address
First Line	:	29 E MAIN ST
Second Line	:
City	:	GOUVERNEUR
State	:	NY
Zip	:	13642-1401
Country	:	US
Telephone Number	:	315-287-3600
Fax Number	:	315-287-4291

Provider Business Practice Location Address
First Line	:	9543 ROUTE 11
Second Line	:
City	:	BREWERTON
State	:	NY
Zip	:	13029-9426
Country	:	US
Telephone Number	:	315-676-3676
Fax Number	:	315-668-6525

Authorized Official
Title or Position	:	THIRD PARTY ADMINISTRATOR
Name	:	ELIZABETH M MARLOW
Credential	:
Telephone Number	:	315-287-3600

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	07/04/2024

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