Provider Demographics
NPI:1174639041
Name:MEDICINE MART LTC, LLC
Entity Type:Organization
Organization Name:MEDICINE MART LTC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:STERLING
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:910-653-6805
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:TABOR CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28463-0550
Mailing Address - Country:US
Mailing Address - Phone:910-653-6804
Mailing Address - Fax:910-653-4915
Practice Address - Street 1:214 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TABOR CITY
Practice Address - State:NC
Practice Address - Zip Code:28463-1904
Practice Address - Country:US
Practice Address - Phone:910-653-6804
Practice Address - Fax:910-653-4915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0845353336L0003X
NC084353336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0245845Medicaid