Provider Demographics
NPI:1497928626
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:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ASHLEY
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-489-9330
Mailing Address - Street 1:211 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-2504
Mailing Address - Country:US
Mailing Address - Phone:662-473-4426
Mailing Address - Fax:662-473-4427
Practice Address - Street 1:211 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965-2504
Practice Address - Country:US
Practice Address - Phone:662-473-4426
Practice Address - Fax:662-473-4427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED-MART HOME CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-09
Last Update Date:2011-09-08
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