Healthcare Provider Details

I. General information

NPI: 1942947460
Provider Name (Legal Business Name): NMMB ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20035 JETTON RD STE B
CORNELIUS NC
28031-8277
US

IV. Provider business mailing address

19701 BETHEL CHURCH RD STE 103-215
CORNELIUS NC
28031-4072
US

V. Phone/Fax

Practice location:
  • Phone: 704-255-6172
  • Fax:
Mailing address:
  • Phone: 704-578-4360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE ROSEBOROUGH EASTMAN
Title or Position: PHARMACIST/ OWNER
Credential: PHARM D
Phone: 704-255-6172