Provider Demographics
NPI:1861404139
Name:DEL MAR MEDICAL, INC.
Entity type:Organization
Organization Name:DEL MAR MEDICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-754-4667
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37121-0787
Mailing Address - Country:US
Mailing Address - Phone:615-754-4667
Mailing Address - Fax:615-758-5878
Practice Address - Street 1:198 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:MT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3324
Practice Address - Country:US
Practice Address - Phone:615-754-4667
Practice Address - Fax:615-754-2582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20783336I0012X, 3336M0002X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0355760002Medicare ID - Type Unspecified