Healthcare Provider Details

I. General information

NPI: 1619011954
Provider Name (Legal Business Name): MITCHELL LEWIS ENNIS I RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 GARY AVE
FAIRFIELD AL
35064-1348
US

IV. Provider business mailing address

2525 CANTERBURY RD
BIRMINGHAM AL
35223-1909
US

V. Phone/Fax

Practice location:
  • Phone: 205-785-4343
  • Fax:
Mailing address:
  • Phone: 205-871-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6673
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: