1639156219 NPI number — MIMBS DRUG CO.

Table of content: (NPI 1639156219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639156219 NPI number — MIMBS DRUG CO.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIMBS DRUG CO.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DIXIE CITY PHARMACY # 4
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639156219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4251-H WINDER HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWERY BRANCH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30542-4623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-965-9101
Provider Business Mailing Address Fax Number:
770-965-9658

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4251-H WINDER HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLOWERY BRANCH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30542-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-965-9101
Provider Business Practice Location Address Fax Number:
770-965-9658
Provider Enumeration Date:
12/27/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MIMBS
Authorized Official First Name:
EDDIE
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
770-965-9101

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PHRE008007 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHRE008007 . This is a "STATE LISC NUMBER" identifier , issued by the state of ( GU ) . This identifiers is of the category "OTHER".
  • Identifier: 1142998 . This is a "NCPDP #" identifier , issued by the state of ( GU ) . This identifiers is of the category "OTHER".
  • Identifier: 00714887A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".