Healthcare Provider Details

I. General information

NPI: 1962755256
Provider Name (Legal Business Name): MIRROR LAKE DRUGS & MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 DALLAS HWY
VILLA RICA GA
30180-1237
US

IV. Provider business mailing address

895 DALLAS HWY
VILLA RICA GA
30180-1237
US

V. Phone/Fax

Practice location:
  • Phone: 770-462-1152
  • Fax: 770-462-1154
Mailing address:
  • Phone: 770-462-1152
  • Fax: 770-462-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHRE009876
License Number StateGA

VIII. Authorized Official

Name: MR. CHYMAR OKORIE IHEKWEREME
Title or Position: PIC/CHIEF EXECUTIVE OFFICER
Credential: RPH
Phone: 770-462-1152