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General NPI Number Information
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NPI Number | 1245895929
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Entity Type | Organization
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Legal Business Name | GRACIOUS HEALTH MART LLC
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Dates
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Enumeration Date | 05/07/2019
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 4237 SALISBURY RD BLDG 3
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City | JACKSONVILLE
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State | FL
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Zip | 32216-8029
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Country | US
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Telephone | 904-683-4298
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Fax | 904-683-4922
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Provider Business Mailing Address
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Address Line | 3480 EASTERN BLVD
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City | MONTGOMERY
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State | AL
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Zip | 36116-1700
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Country | US
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Telephone | 334-819-4500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRYSTAL MIMS
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Credential |
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Telephone | 334-819-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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