Provider Demographics
NPI:1710698717
Name:MOBILE INFIRMARY ASSOCIATION
Entity Type:Organization
Organization Name:MOBILE INFIRMARY ASSOCIATION
Other - Org Name:MIMC SPECIALTY AND HOME INFUSION PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-625-8454
Mailing Address - Street 1:PO BOX 1468
Mailing Address - Street 2:
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7101 US HIGHWAY 90
Practice Address - Street 2:BUILDING B, SUITE B100
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-9512
Practice Address - Country:US
Practice Address - Phone:251-625-8445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-09
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL302591Medicaid