MEDICARE: KENMORE VILLAGE PHARMACY, LLC.

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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1518835644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENMORE VILLAGE PHARMACY, LLC.

Provider Business Mailing Address
First Line	:	747 KENMORE AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14223-3106
Country	:	US
Telephone Number	:	716-262-0233
Fax Number	:	716-262-0238

Provider Business Practice Location Address
First Line	:	747 KENMORE AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14223-3106
Country	:	US
Telephone Number	:	716-262-0233
Fax Number	:	716-262-0238

Authorized Official
Title or Position	:	OWNER
Name	:	CYRUS ARDALAN
Credential	:	RPH
Telephone Number	:	716-796-5668

Provider Enumeration Date	:	10/29/2025
Last Update Date	:	10/29/2025

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