Healthcare Provider Details

I. General information

NPI: 1861407496
Provider Name (Legal Business Name): MEDI MART PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 GEORGETOWN RD NW
CLEVELAND TN
37312-1309
US

IV. Provider business mailing address

PO BOX 3240
CLEVELAND TN
37320-3240
US

V. Phone/Fax

Practice location:
  • Phone: 423-472-5548
  • Fax: 423-472-6400
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number0000000354
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0000000354
License Number StateTN

VIII. Authorized Official

Name: JOE MOORE
Title or Position: OWNER
Credential:
Phone: 423-476-7947