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General NPI Number Information
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NPI Number | 1962755256
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Entity Type | Organization
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Legal Business Name | MIRROR LAKE DRUGS & MEDICAL SERVICES LLC
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Dates
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Enumeration Date | 10/24/2012
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Last Update Date | 10/22/2020
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Provider Practice Location Address
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Address Line | 895 DALLAS HWY
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City | VILLA RICA
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State | GA
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Zip | 30180-1237
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Country | US
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Telephone | 770-462-1152
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Fax | 770-462-1154
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Provider Business Mailing Address
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Address Line | 895 DALLAS HWY
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City | VILLA RICA
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State | GA
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Zip | 30180-1237
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Country | US
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Telephone | 770-462-1152
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Fax | 770-462-1154
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Authorized Official
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Title or Position | PIC/CHIEF EXECUTIVE OFFICER
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Name | MR. CHYMAR OKORIE IHEKWEREME
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Credential | RPH
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Telephone | 770-462-1152
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PHRE009876
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License Number State | GA
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