Provider Demographics
NPI:1447608583
Name:MED MART PHARMACY LLC
Entity Type:Organization
Organization Name:MED MART PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-283-3872
Mailing Address - Street 1:27012 HAVELOCK DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3639
Mailing Address - Country:US
Mailing Address - Phone:313-283-3872
Mailing Address - Fax:
Practice Address - Street 1:25850 EUREKA RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-4924
Practice Address - Country:US
Practice Address - Phone:313-283-3872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty