Provider Demographics
NPI:1689272452
Name:MIRROR LAKE DRUGS & MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:MIRROR LAKE DRUGS & MEDICAL SERVICES LLC
Other - Org Name:ROCKMART PHARMACY & MEDICAL SERVICES LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST/ CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHYMAR
Authorized Official - Middle Name:OKORIE
Authorized Official - Last Name:IHEKWEREME
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-462-1152
Mailing Address - Street 1:895 DALLAS HWY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1237
Mailing Address - Country:US
Mailing Address - Phone:770-462-1152
Mailing Address - Fax:770-462-1154
Practice Address - Street 1:895 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1237
Practice Address - Country:US
Practice Address - Phone:770-462-1152
Practice Address - Fax:770-462-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy