MEDICARE: MEDI MART PHARMACY

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	3336C0003X	Community/Retail Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies	0000000354	TN
3	333600000X	Pharmacy	0000000354	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4439255	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1861407496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDI MART PHARMACY

Provider Business Mailing Address
First Line	:	PO BOX 3240
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37320-3240
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5030 GEORGETOWN RD NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-1309
Country	:	US
Telephone Number	:	423-472-5548
Fax Number	:	423-472-6400

Authorized Official
Title or Position	:	OWNER
Name	:	JOE MOORE
Credential	:
Telephone Number	:	423-476-7947

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	04/20/2008

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Directions to “MEDI MART PHARMACY ” Practice Location

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