MEDICARE: KMART STORES OF IL LLC 3105

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		IL

General Provider Information

NPI Number	:	1699109496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMART STORES OF IL LLC 3105

Provider Business Mailing Address
First Line	:	2901 E LINCOLNWAY
Second Line	:
City	:	STERLING
State	:	IL
Zip	:	61081-1780
Country	:	US
Telephone Number	:	815-626-5862
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 E LINCOLNWAY
Second Line	:
City	:	STERLING
State	:	IL
Zip	:	61081-1780
Country	:	US
Telephone Number	:	815-626-5862
Fax Number	:

Authorized Official
Title or Position	:	PDM
Name	:	MR. RONALD SCHWEIHS
Credential	:	PHARM D
Telephone Number	:	815-626-5862

Provider Enumeration Date	:	08/28/2013
Last Update Date	:	07/21/2022

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