Provider Demographics
NPI:1154973774
Name:MIMMS, P
Entity type:Individual
Prefix:
First Name:P
Middle Name:
Last Name:MIMMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 HAYDEN AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-7967
Mailing Address - Country:US
Mailing Address - Phone:508-740-9000
Mailing Address - Fax:
Practice Address - Street 1:339 POND ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:MA
Practice Address - Zip Code:01721-2327
Practice Address - Country:US
Practice Address - Phone:508-740-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-13
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist