Healthcare Provider Details

I. General information

NPI: 1144228412
Provider Name (Legal Business Name): MED-MART HOME CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MAGGIE DR
PONTOTOC MS
38863-8631
US

IV. Provider business mailing address

PO BOX 616
PONTOTOC MS
38863-0616
US

V. Phone/Fax

Practice location:
  • Phone: 662-489-9330
  • Fax: 662-489-9363
Mailing address:
  • Phone: 662-489-9330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number1132590001
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1132590001
License Number StateMS

VIII. Authorized Official

Name: MR. KENNEY BLEASE BUTLER
Title or Position: CO-OWNER
Credential:
Phone: 662-489-9330