Provider Demographics
NPI:1346563913
Name:MIMS, CHERIE FONTENOT (DPH)
Entity Type:Individual
Prefix:
First Name:CHERIE
Middle Name:FONTENOT
Last Name:MIMS
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 BEKAH RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2802
Mailing Address - Country:US
Mailing Address - Phone:901-605-8007
Mailing Address - Fax:
Practice Address - Street 1:1620 CENTURY CENTER PKWY
Practice Address - Street 2:SUITE 109
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-0181
Practice Address - Country:US
Practice Address - Phone:901-381-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000008331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist