Provider Demographics
NPI:1639156219
Name:MIMBS DRUG CO.
Entity Type:Organization
Organization Name:MIMBS DRUG CO.
Other - Org Name:DIXIE CITY PHARMACY # 4
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:770-965-9101
Mailing Address - Street 1:4251-H WINDER HWY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-4623
Mailing Address - Country:US
Mailing Address - Phone:770-965-9101
Mailing Address - Fax:770-965-9658
Practice Address - Street 1:4251-H WINDER HWY
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-4623
Practice Address - Country:US
Practice Address - Phone:770-965-9101
Practice Address - Fax:770-965-9658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE008007333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GUPHRE008007OtherSTATE LISC NUMBER
GU1142998OtherNCPDP #
GA00714887AMedicaid
GA00714887AMedicaid