Provider Demographics
NPI:1598768699
Name:MEDICAL MALL PHARMACY INC
Entity Type:Organization
Organization Name:MEDICAL MALL PHARMACY INC
Other - Org Name:MEDICAL MALL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SYSTEMS ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-8432
Mailing Address - Street 1:1 MEDICAL PARK BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 106-E
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-2888
Practice Address - Fax:423-844-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN29643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN008503257Medicaid
4428719OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TN008503257Medicaid