MEDICARE: MEDI-MART PHARMACY 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	333600000X	Pharmacy	0406858	AR

General Provider Information

NPI Number	:	1326033515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDI-MART PHARMACY INC

Provider Business Mailing Address
First Line	:	1415 PINECREST SHOPPING CTR
Second Line	:
City	:	BRINKLEY
State	:	AR
Zip	:	72021-2000
Country	:	US
Telephone Number	:	870-734-3088
Fax Number	:	870-734-1367

Provider Business Practice Location Address
First Line	:	1415 PINECREST SHOPPING CTR
Second Line	:
City	:	BRINKLEY
State	:	AR
Zip	:	72021-2000
Country	:	US
Telephone Number	:	870-734-3088
Fax Number	:	870-734-1367

Authorized Official
Title or Position	:	OWNER
Name	:	MR. BENJAMIN ALLEN MYERS
Credential	:	RPH
Telephone Number	:	870-734-3088

Provider Enumeration Date	:	09/14/2005
Last Update Date	:	08/22/2020

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