Organization
MEDICAL MALL PHARMACY INC
Active
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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