Provider Demographics
NPI:1588088363
Name:MIMS, JACQUELYN DENISE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:DENISE
Last Name:MIMS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10019 TECUM RD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90240-3620
Mailing Address - Country:US
Mailing Address - Phone:562-806-4557
Mailing Address - Fax:562-806-3497
Practice Address - Street 1:10019 TECUM RD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90240-3620
Practice Address - Country:US
Practice Address - Phone:562-806-4557
Practice Address - Fax:562-806-3497
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH415751835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist