=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013004217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICINE MART COLUMBIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2006
-----------------------------------------------------
Last Update Date | 07/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3729 ROSEWOOD DR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-231-2003
-----------------------------------------------------
Fax | 803-231-2004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3729 ROSEWOOD DR
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29205-3531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-231-2003
-----------------------------------------------------
Fax | 803-231-2004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHARMACIST-IN-CHARGE
-----------------------------------------------------
Name | ANDREW DAVID WALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 803-231-2003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 17915
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------