Provider Demographics
NPI:1528041373
Name:MED MART LEX LLC
Entity Type:Organization
Organization Name:MED MART LEX LLC
Other - Org Name:MEDICINE MART OF LEXINGTON SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLEATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-957-5969
Mailing Address - Street 1:348B 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 1:348B 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:2005-11-25
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC162423336C0003X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155728OtherPK
SC716242Medicaid