Healthcare Provider Details

I. General information

NPI: 1386131050
Provider Name (Legal Business Name): MED-MART PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MIDDLETOWN CIR
FAIRMONT WV
26554-2015
US

IV. Provider business mailing address

2524 SUN TRL
MORGANTOWN WV
26505-1131
US

V. Phone/Fax

Practice location:
  • Phone: 304-367-9122
  • Fax: 304-367-9125
Mailing address:
  • Phone: 304-690-6165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberSP0552522
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: IBRAHIM KADDOURAH
Title or Position: OWNER/PIC
Credential:
Phone: 304-367-9122