Provider Demographics
NPI:1073822870
Name:FAMILY MED-MART LLC
Entity Type:Organization
Organization Name:FAMILY MED-MART LLC
Other - Org Name:WHITEHALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/AGENT
Authorized Official - Prefix:
Authorized Official - First Name:YAMROTE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-598-3001
Mailing Address - Street 1:2833 BRYN MAWR DR
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-8915
Mailing Address - Country:US
Mailing Address - Phone:614-598-3001
Mailing Address - Fax:614-547-7742
Practice Address - Street 1:4770 INDIANOLA AVE STE 208
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1876
Practice Address - Country:US
Practice Address - Phone:614-547-7766
Practice Address - Fax:614-547-7742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
OH0226596503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2127361OtherPK
OH3090542Medicaid