1386131050 NPI number — MED-MART PHARMACY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386131050 NPI number — MED-MART PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED-MART PHARMACY LLC
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:
MED-MART PHARMACY FAIRMONT
Provider Other Organization Name Type Code:
3
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:
1386131050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2524 SUN TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26505-1131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-690-6165
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 MIDDLETOWN CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554-2015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-367-9122
Provider Business Practice Location Address Fax Number:
304-367-9125
Provider Enumeration Date:
04/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KADDOURAH
Authorized Official First Name:
IBRAHIM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PIC
Authorized Official Telephone Number:
304-367-9122

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  SP0552522 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2176926 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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