Provider Demographics
NPI:1275536997
Name:MEDICAL MALL PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL MALL PHARMACY INC
Other - Org Name:WELLMONT OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SYSTEMS ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-8432
Mailing Address - Street 1:130 W RAVINE RD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3837
Mailing Address - Country:US
Mailing Address - Phone:423-224-6860
Mailing Address - Fax:423-224-5654
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-6860
Practice Address - Fax:423-224-5654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TNC34133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3130747Medicaid
4433378OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA8517916Medicaid