Basic Information
| Provider Information | |||||||||
| NPI: | 1245895929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACIOUS HEALTH MART LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MASS PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3480 EASTERN BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361161700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348194500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4237 SALISBURY RD STE 301 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322160908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046834298 | ||||||||
| FaxNumber: | 9046834922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2019 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIMS | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3348194500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336L0003X | Y | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | FL | NONE | OTHER |