Provider Demographics
NPI:1316191349
Name:MEDICAL MALL PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL MALL PHARMACY INC
Other - Org Name:STONE DRIVE OUTPATIENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OUTPATIENT PHARMAC
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-8435
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 1-B
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:SUITE 1-B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3256
Practice Address - Country:US
Practice Address - Phone:423-224-3555
Practice Address - Fax:423-224-3560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4582333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4442062OtherNCPDP PROVIDER IDENTIFICATION NUMBER