Provider Demographics
NPI:1144228412
Name:MED-MART HOME CARE INC
Entity Type:Organization
Organization Name:MED-MART HOME CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNEY
Authorized Official - Middle Name:BLEASE
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-489-9330
Mailing Address - Street 1:PO BOX 616
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-0616
Mailing Address - Country:US
Mailing Address - Phone:662-489-9330
Mailing Address - Fax:
Practice Address - Street 1:225 MAGGIE DR
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-8631
Practice Address - Country:US
Practice Address - Phone:662-489-9330
Practice Address - Fax:662-489-9363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1132590001332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0440402Medicaid
MS0440402Medicaid