Provider Demographics
NPI:1740501543
Name:MED-MART PHARMACY LLC
Entity type:Organization
Organization Name:MED-MART PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIZEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-878-1200
Mailing Address - Street 1:87 CVB DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741
Mailing Address - Country:US
Mailing Address - Phone:606-878-1200
Mailing Address - Fax:606-878-1214
Practice Address - Street 1:87 C V B DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1096
Practice Address - Country:US
Practice Address - Phone:606-878-1200
Practice Address - Fax:606-878-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
KYP074003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831913OtherNCPDP PROVIDER IDENTIFICATION NUMBER
KY7100120850Medicaid
1831913OtherNCPDP PROVIDER IDENTIFICATION NUMBER