Provider Demographics
NPI:1841761947
Name:MAC'S MEDICINE MART DBA UNIQUE BOUTIQUE
Entity Type:Organization
Organization Name:MAC'S MEDICINE MART DBA UNIQUE BOUTIQUE
Other - Org Name:UNIQUE BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:423-245-2181
Mailing Address - Street 1:1455 E CENTER ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2501
Mailing Address - Country:US
Mailing Address - Phone:423-246-2646
Mailing Address - Fax:423-765-9111
Practice Address - Street 1:1455 E CENTER ST STE 2B
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2501
Practice Address - Country:US
Practice Address - Phone:423-246-2646
Practice Address - Fax:423-765-9111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MAC'S MEDICINE MART, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-16
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier