=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538140769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIMBS DRUG CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1077 JESSE JEWELL PKWY SW
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-6103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-536-3329
-----------------------------------------------------
Fax | 770-536-0462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1077 JESSE JEWELL PKWY SW
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-6103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-536-3329
-----------------------------------------------------
Fax | 770-536-0462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EDDIE H MIMBS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 770-536-3329
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | PHRE003427
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------