Healthcare Provider Details

I. General information

NPI: 1346319043
Provider Name (Legal Business Name): DANIEL ROY MIMS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 INTERSTATE PARK DR SUITE 422
MONTGOMERY AL
36109-5428
US

IV. Provider business mailing address

400 INTERSTATE PARK DR SUITE 422
MONTGOMERY AL
36109-5428
US

V. Phone/Fax

Practice location:
  • Phone: 334-356-7627
  • Fax: 334-356-7647
Mailing address:
  • Phone: 334-356-7627
  • Fax: 334-356-7647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13854
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: