Active NPI
Magic Mart Pharmacy,Inc
- Pharmacy
- Indianola, MS
National Provider Identifier
1194804591
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacy
- License
- 01301
- Legal business name
- MAGIC MART PHARMACY,INC
- Practice address
- 903 Highway 82 E BLDG G
Indianola, MS 38751-2325 - Phone
- (662) 887-4135
- Fax
- (662) 887-9703
- NPI assigned
- Nov 4, 2006
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Guy M Malone
- Title
- President
- Phone
- (662) 887-4135
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | 01301 | MS | Primary |
Addresses
Primary practice location
903 Highway 82 E BLDG G
Indianola, MS 38751-2325
Mailing address
903 Highway 82 E BLDG G
Indianola, MS 38751-2325
Phone (662) 887-4135
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 0966510001 | Other | MS | MEDICARE DME |
| 2517324 | Other | MS | NCPDP |
| 00330007 | Medicaid | MS | |
| 00440170 | Other | MS | MEDICAID DME |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MS
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20181110000201 | MS | Part B Supplier - Mass Immunization (Roster Biller Only) | 5698895118 | Practice locations: Indianola, MS |
National Provider Directory
National Provider DirectoryNPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1162598400000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1576713600000",
"number": "1194804591",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "903 HIGHWAY 82 E BLDG G",
"city": "INDIANOLA",
"state": "MS",
"postal_code": "387512325",
"telephone_number": "662-887-4135",
"fax_number": "662-887-9703"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "903 HIGHWAY 82 E BLDG G",
"city": "INDIANOLA",
"state": "MS",
"postal_code": "387512325",
"telephone_number": "662-887-4135",
"fax_number": "662-887-9703"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "MAGIC MART PHARMACY,INC",
"organizational_subpart": "NO",
"enumeration_date": "2006-11-04",
"last_updated": "2019-12-19",
"certification_date": "2019-12-19",
"status": "A",
"authorized_official_last_name": "MALONE",
"authorized_official_first_name": "GUY",
"authorized_official_middle_name": "M",
"authorized_official_title_or_position": "PRESIDENT",
"authorized_official_telephone_number": "662-887-4135"
},
"taxonomies": [
{
"code": "333600000X",
"taxonomy_group": "",
"desc": "Pharmacy",
"state": "MS",
"license": "01301",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICARE DME",
"identifier": "0966510001",
"state": "MS"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NCPDP",
"identifier": "2517324",
"state": "MS"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00330007",
"state": "MS"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICAID DME",
"identifier": "00440170",
"state": "MS"
}
],
"endpoints": [],
"other_names": []
}Other providers in Indianola, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 19, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.