1114098803 NPI number — MART BEAUTY SUPPLY

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 1114098803 NPI number — MART BEAUTY SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MART BEAUTY SUPPLY
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:
1114098803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3031 PETERS CREEK RD NW STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24019-2768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-562-2728
Provider Business Mailing Address Fax Number:
540-562-2764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3031 PETERS CREEK RD NW STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24019-2768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-562-2728
Provider Business Practice Location Address Fax Number:
540-562-2764
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PATTERSON
Authorized Official First Name:
HILDA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
540-562-2728

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  091855 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4670699 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 264475 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 277911 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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