Provider Demographics
NPI:1538140769
Name:MIMBS DRUG CO
Entity Type:Organization
Organization Name:MIMBS DRUG CO
Other - Org Name:DIXIE CITY PHARMACY 1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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 1:1077 JESSE JEWELL PKWY SW
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-6103
Mailing Address - Country:US
Mailing Address - Phone:770-536-3329
Mailing Address - Fax:770-536-0462
Practice Address - Street 1:1077 JESSE JEWELL PKWY SW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-6103
Practice Address - Country:US
Practice Address - Phone:770-536-3329
Practice Address - Fax:770-536-0462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE003427333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00025891BMedicaid
GA00025891AMedicaid
GAPHRE003427OtherSTATE LISC NO
GA1102689OtherNCPDP
GA1102689OtherNCPDP
0127180001Medicare NSC
GAPHRE003427OtherSTATE LISC NO