Provider Demographics
NPI:1598360448
Name:SIMS, BRIA
Entity Type:Individual
Prefix:
First Name:BRIA
Middle Name:
Last Name:SIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16147 N SQUIRE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-7565
Mailing Address - Country:US
Mailing Address - Phone:618-231-4431
Mailing Address - Fax:
Practice Address - Street 1:2700 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2342
Practice Address - Country:US
Practice Address - Phone:618-242-2074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist