1316191349 NPI number — MEDICAL MALL PHARMACY INC

Table of content: RACHEL FERRARESE (NPI 1245972066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316191349 NPI number — MEDICAL MALL PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL MALL PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316191349
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 W STONE DR
Provider Second Line Business Mailing Address:
SUITE 1-B
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 W STONE DR
Provider Second Line Business Practice Location Address:
SUITE 1-B
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-3256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-224-3555
Provider Business Practice Location Address Fax Number:
423-224-3560
Provider Enumeration Date:
11/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SWEET
Authorized Official First Name:
CARRIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OUTPATIENT PHARMAC
Authorized Official Telephone Number:
423-230-8435

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  4582 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4442062 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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