Provider Demographics
NPI:1508447418
Name:MED MART LEX LLC
Entity Type:Organization
Organization Name:MED MART LEX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:GLEATON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:803-957-5969
Mailing Address - Street 1:348 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-2657
Mailing Address - Country:US
Mailing Address - Phone:803-957-5969
Mailing Address - Fax:803-808-1829
Practice Address - Street 1:348 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2657
Practice Address - Country:US
Practice Address - Phone:803-957-5969
Practice Address - Fax:803-808-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC716242Medicaid