Healthcare Provider Details

I. General information

NPI: 1174639041
Provider Name (Legal Business Name): MEDICINE MART LTC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 S MAIN ST
TABOR CITY NC
28463-1904
US

IV. Provider business mailing address

PO BOX 550
TABOR CITY NC
28463-0550
US

V. Phone/Fax

Practice location:
  • Phone: 910-653-6804
  • Fax: 910-653-4915
Mailing address:
  • Phone: 910-653-6804
  • Fax: 910-653-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number08435
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number084535
License Number StateNC

VIII. Authorized Official

Name: STERLING G KOONCE
Title or Position: MANAGING AGENT
Credential: RPH
Phone: 910-653-6805