Mirror Lake Drugs & Medical Services LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

PHRE009876 Issued in GA

Legal business name

MIRROR LAKE DRUGS & MEDICAL SERVICES LLC

Practice address

895 Dallas Hwy
Villa Rica, GA 30180-1237

Phone

(770) 462-1152

Fax

(770) 462-1154

NPI assigned

Oct 24, 2012

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Chymar Okorie Ihekwereme, RPHNPI 1548514631

Title

Pic/Chief Executive Officer

Phone

(770) 462-1152

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• Rockmart Pharmacy & Medical Services LLC Former legal business name

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Chymar Okorie Ihekwereme, RPH

  • Pharmacist
  • Rockmart, GA
  • NPI 1548514631
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1351036800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603324800000",
    "number": "1962755256",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "895 DALLAS HWY",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301801237",
            "telephone_number": "770-462-1152",
            "fax_number": "770-462-1154"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "895 DALLAS HWY",
            "city": "VILLA RICA",
            "state": "GA",
            "postal_code": "301801237",
            "telephone_number": "770-462-1152",
            "fax_number": "770-462-1154"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIRROR LAKE DRUGS & MEDICAL SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-24",
        "last_updated": "2020-10-22",
        "certification_date": "2020-10-22",
        "status": "A",
        "authorized_official_last_name": "IHEKWEREME",
        "authorized_official_first_name": "CHYMAR",
        "authorized_official_middle_name": "OKORIE",
        "authorized_official_title_or_position": "PIC/CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "770-462-1152",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "RPH"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pharmacist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "GA",
            "license": "PHRE009876",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003129213A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2137507",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rockmart Pharmacy & Medical Services LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Victoria Mearns
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• Michael Beckerman DMD & Associates, LLC
• Whitney Marie Mighty
• Mirror Lake Drugs & Medical Services LLC
• Mobolaji Shalom Oyebanjo, Inc
• Allyson Moffatt, LPC
• Danielle Monroe
• Fredric A Moore, D.M.D.
• Eric L Morante, PT

• All providers in Villa Rica, GA
• Community/Retail Pharmacy in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.