Basic Information
Provider Information | |||||||||
NPI: | 1962519140 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KPH HEALTHCARE SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KINNEY DRUGS #23 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 29 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | GOUVERNEUR | ||||||||
State: | NY | ||||||||
PostalCode: | 136421401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152873600 | ||||||||
FaxNumber: | 3152874291 | ||||||||
Practice Location | |||||||||
Address1: | 97 MORRISVILLE PLAZA | ||||||||
Address2: |   | ||||||||
City: | MORRISVILLE | ||||||||
State: | VT | ||||||||
PostalCode: | 05661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028885244 | ||||||||
FaxNumber: | 8028886981 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 04/04/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEIR | ||||||||
AuthorizedOfficialFirstName: | LISA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | THIRD PARTY ADMINISTRATO | ||||||||
AuthorizedOfficialTelephone: | 3152873600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 0380002052 | VT | N |   | Suppliers | Pharmacy |   | 3336C0003X |   |   | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 0006693 | 05 | VT |   | MEDICAID | 4702052 | 01 |   | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |