Medical Mall Pharmacy Inc

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

C3413 Issued in TN

Legal business name

MEDICAL MALL PHARMACY INC

Doing business as

Wellmont Outpatient Pharmacy

Practice address

130 W Ravine Rd
Kingsport, TN 37660-3837

Phone

(423) 224-6860

Fax

(423) 224-5654

NPI assigned

May 27, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kristine Hagee

Title

Pharmacy Systems Analyst

Phone

(423) 230-8432

Specialties & licenses 2

Addresses

Other identifiers 3

Other names 1

• Wellmont Outpatient Pharmacy Doing business as

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• Wellmont Health System

  • General Acute Care Hospital
  • Kingsport, TN
  • NPI 1487690400

  Member Of

  NPD member

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1117152000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1259798400000",
    "number": "1275536997",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "130 W RAVINE RD",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376603837",
            "telephone_number": "423-224-6860",
            "fax_number": "423-224-5654"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "130 W RAVINE RD",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376603837",
            "telephone_number": "423-224-6860",
            "fax_number": "423-224-5654"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEDICAL MALL PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-05-27",
        "last_updated": "2009-12-03",
        "status": "A",
        "authorized_official_last_name": "HAGEE",
        "authorized_official_first_name": "KRISTINE",
        "authorized_official_title_or_position": "PHARMACY SYSTEMS ANALYST",
        "authorized_official_telephone_number": "423-230-8432"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "TN",
            "license": "C3413",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3130747",
            "state": "TN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "4433378",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8517916",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Wellmont Outpatient Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community/Retail Pharmacy in Kingsport, TN
• Providers in Kingsport, TN by specialty
• Community/Retail Pharmacy in Tennessee

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.