Provider Demographics
NPI:1013004217
Name:MEDICINE MART COLUMBIA, INC.
Entity Type:Organization
Organization Name:MEDICINE MART COLUMBIA, INC.
Other - Org Name:MEDICINE MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-231-2003
Mailing Address - Street 1:3729 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-3531
Mailing Address - Country:US
Mailing Address - Phone:803-231-2003
Mailing Address - Fax:803-231-2004
Practice Address - Street 1:3729 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205
Practice Address - Country:US
Practice Address - Phone:803-231-2003
Practice Address - Fax:803-231-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC179153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC71791DMedicaid
SC767123Medicaid
2092208OtherPK