Healthcare Provider Details

I. General information

NPI: 1740501543
Provider Name (Legal Business Name): MED-MART PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 C V B DR
LONDON KY
40741-1096
US

IV. Provider business mailing address

87 CVB DR
LONDON KY
40741
US

V. Phone/Fax

Practice location:
  • Phone: 606-878-1200
  • Fax: 606-878-1214
Mailing address:
  • Phone: 606-878-1200
  • Fax: 606-878-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberP07400
License Number StateKY

VIII. Authorized Official

Name: MICHAEL SIZEMORE
Title or Position: PRESIDENT
Credential:
Phone: 606-878-1200