Provider Demographics
NPI:1689279028
Name:MIMMS, AMY MARIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:MARIE
Last Name:MIMMS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:486 OAK TREE WAY
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40071-7184
Mailing Address - Country:US
Mailing Address - Phone:501-758-2744
Mailing Address - Fax:502-893-8056
Practice Address - Street 1:143 THIERMAN LN
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:KY
Practice Address - Zip Code:40207-5009
Practice Address - Country:US
Practice Address - Phone:502-893-8110
Practice Address - Fax:502-893-8056
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016218183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist