=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235779356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIMI LE RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2020
-----------------------------------------------------
Last Update Date | 01/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 827 FAIRMONT RD STE 104
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26501-3857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-639-9027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25153 CUTGRASS TER
-----------------------------------------------------
City | ALDIE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20105-5639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP0011912
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------