MEDICARE: WOODYS LONGBRANCH PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	PHRE009678	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1160340	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1790093102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODYS LONGBRANCH PHARMACY INC

Provider Business Mailing Address
First Line	:	WOODY'S LONGBRANCH PHARMACY
Second Line	:	P.O. BOX 309
City	:	DAHLONEGA
State	:	GA
Zip	:	30533
Country	:	US
Telephone Number	:	706-867-9493
Fax Number	:	706-867-9495

Provider Business Practice Location Address
First Line	:	130 LONG BRANCH RD
Second Line	:
City	:	DAHLONEGA
State	:	GA
Zip	:	30533-7132
Country	:	US
Telephone Number	:	706-867-9493
Fax Number	:	706-867-9495

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	KEVIN WOODY
Credential	:
Telephone Number	:	678-316-3031

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	03/01/2011

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