Organization
MIRROR LAKE DRUGS & MEDICAL SERVICES LLC
Active
Other names
Rockmart Pharmacy & Medical Services LLC
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CHYMAR OKORIE IHEKWEREME RPH (PIC/CHIEF EXECUTIVE OFFICER)
(770) 462-1152
Entity
Organization
Contact information
Practice address
895 DALLAS HWY, VILLA RICA, GA 30180-1237
(770) 462-1152
(770) 462-1154
Mailing address
895 DALLAS HWY, VILLA RICA, GA 30180-1237
(770) 462-1152
(770) 462-1154
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
PHRE009876
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003129213A
—
GA
01
—
2137507
PK
—
Enumeration date
10/24/2012
Last updated
10/22/2020
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