Organization
MEDICAL MALL PHARMACY INC
Active
Other names
Wellmont Outpatient Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
KRISTINE HAGEE (PHARMACY SYSTEMS ANALYST)
(423) 230-8432
Entity
Organization
Contact information
Practice address
130 W RAVINE RD, KINGSPORT, TN 37660-3837
(423) 224-6860
(423) 224-5654
Mailing address
130 W RAVINE RD, KINGSPORT, TN 37660-3837
(423) 224-6860
(423) 224-5654
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
C3413
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3130747
—
TN
01
—
4433378
NCPDP PROVIDER IDENTIFICATION NUMBER
—
05
—
8517916
—
VA
Enumeration date
05/27/2005
Last updated
12/03/2009
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