Basic Information
| Provider Information | |||||||||
| NPI: | 1699127357 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER COMMUNITY PHARMACY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KAISER COMMUNITY PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 BENEDICT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448572346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196681078 | ||||||||
| FaxNumber: | 4196635837 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 BENEDICT AVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448572346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196681078 | ||||||||
| FaxNumber: | 4196635837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 03/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | ELMER | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 4196688101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | PMY.022651150-03 | OH | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2162323 | 01 | PK | OTHER |