Healthcare Provider Details

I. General information

NPI: 1073424024
Provider Name (Legal Business Name): ERICA MIMMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 FAIRWAY VILLAGE PL
WALDORF MD
20602-5104
US

IV. Provider business mailing address

4535 FAIRWAY VILLAGE PL
WALDORF MD
20602-5104
US

V. Phone/Fax

Practice location:
  • Phone: 227-722-4156
  • Fax: 227-722-4157
Mailing address:
  • Phone: 227-722-4156
  • Fax: 227-722-4157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberT23826
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: