Provider Demographics
NPI:1245895929
Name:GRACIOUS HEALTH MART LLC
Entity type:Organization
Organization Name:GRACIOUS HEALTH MART LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-819-4500
Mailing Address - Street 1:3480 EASTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1700
Mailing Address - Country:US
Mailing Address - Phone:334-819-4500
Mailing Address - Fax:
Practice Address - Street 1:4237 SALISBURY RD BLDG 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8029
Practice Address - Country:US
Practice Address - Phone:904-683-4298
Practice Address - Fax:904-683-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113393600Medicaid