MEDICARE: K & P OPTIMUM 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	3336C0004X	Compounding Pharmacy
2	3336C0003X	Community/Retail Pharmacy	5301009156	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2373087	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1750512190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K & P OPTIMUM INC

Provider Business Mailing Address
First Line	:	4250 N SAGINAW ST
Second Line	:	SUITE D
City	:	FLINT
State	:	MI
Zip	:	48505-5332
Country	:	US
Telephone Number	:	810-785-0363
Fax Number	:	810-785-0381

Provider Business Practice Location Address
First Line	:	4250 N SAGINAW ST
Second Line	:	SUITE D
City	:	FLINT
State	:	MI
Zip	:	48505-5332
Country	:	US
Telephone Number	:	810-785-0363
Fax Number	:	810-785-0381

Authorized Official
Title or Position	:	OWNER / PHARMACIST
Name	:	KAUSHAL PATEL
Credential	:	RPH
Telephone Number	:	810-429-6834

Provider Enumeration Date	:	08/03/2009
Last Update Date	:	04/30/2010

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Directions to “K & P OPTIMUM INC ” Practice Location

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