Provider Demographics
NPI:1962755256
Name:MIRROR LAKE DRUGS & MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:MIRROR LAKE DRUGS & MEDICAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHYMAR
Authorized Official - Middle Name:OKORIE
Authorized Official - Last Name:IHEKWEREME
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-462-1152
Mailing Address - Street 1:895 DALLAS HWY
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1237
Mailing Address - Country:US
Mailing Address - Phone:770-462-1152
Mailing Address - Fax:770-462-1154
Practice Address - Street 1:895 DALLAS HWY
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1237
Practice Address - Country:US
Practice Address - Phone:770-462-1152
Practice Address - Fax:770-462-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183500000X, 333600000X
GAPHRE0098763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003129213AMedicaid
2137507OtherPK