MEDICARE: MEDICAL MALL PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	2964	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4428719	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1598768699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL MALL PHARMACY INC

Provider Business Mailing Address
First Line	:	1 MEDICAL PARK BLVD STE 106
Second Line	:
City	:	BRISTOL
State	:	TN
Zip	:	37620-7430
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 MEDICAL PARK BLVD
Second Line	:	SUITE 106-E
City	:	BRISTOL
State	:	TN
Zip	:	37620-7430
Country	:	US
Telephone Number	:	423-844-2888
Fax Number	:	423-844-2891

Authorized Official
Title or Position	:	PHARMACY SYSTEMS ANALYST
Name	:	KRISTINE HAGEE
Credential	:
Telephone Number	:	423-230-8432

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	04/30/2009

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Directions to “MEDICAL MALL PHARMACY INC ” Practice Location

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