Basic Information
| Provider Information | |||||||||
| NPI: | 1245264175 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KPS CARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDICAL ARTS PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8851 CENTER DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194618551 | ||||||||
| FaxNumber: | 6194618553 | ||||||||
| Practice Location | |||||||||
| Address1: | 8851 CENTER DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194618551 | ||||||||
| FaxNumber: | 6194618553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 06/15/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | KETAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6194618551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0004X | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336C0003X | 52528 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2152187 | 01 | PK | OTHER |