Provider Demographics
NPI:1912304197
Name:ADVANCED MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL GROUP, LLC
Other - Org Name:MEDICINE MART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:T
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:678-985-7246
Mailing Address - Street 1:PO BOX 1860
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29834-1860
Mailing Address - Country:US
Mailing Address - Phone:803-593-3411
Mailing Address - Fax:888-273-1488
Practice Address - Street 1:839 RICHLAND AVE W
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3833
Practice Address - Country:US
Practice Address - Phone:803-649-7437
Practice Address - Fax:803-649-2062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy