Provider Demographics
NPI:1467439760
Name:MIMBS DRUG CO DBA DIXIE CITY PHARMACY # 2
Entity Type:Organization
Organization Name:MIMBS DRUG CO DBA DIXIE CITY PHARMACY # 2
Other - Org Name:DIXIE CITY PHARMACY # 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:MIMBS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-536-3329
Mailing Address - Street 1:4222 MCEVER RD
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566-2237
Mailing Address - Country:US
Mailing Address - Phone:770-536-1099
Mailing Address - Fax:770-536-0577
Practice Address - Street 1:4222 MCEVER RD
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2237
Practice Address - Country:US
Practice Address - Phone:770-536-1099
Practice Address - Fax:770-536-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006004333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1126867OtherNCPDP NUMBER
GAPHRE006004OtherSTATE LISC #
GA00247937AMedicaid
GA00247937AMedicaid