=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598579443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MED MART WECO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2025
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 SUNSET BLVD
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-5914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-791-7043
-----------------------------------------------------
Fax | 803-796-1519
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 SUNSET BLVD
-----------------------------------------------------
City | WEST COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29169-5914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-791-7043
-----------------------------------------------------
Fax | 803-796-1519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL ADAM GLEATON
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 803-957-5969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------